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Prithvi Mruthyunjaya, MD

  • Prithvi Mruthyunjaya

Dr. Mruthyunjaya cares for patients with conditions related to cancer of the eye in both adults and children, either benign, pre-cancerous or eye cancer. These conditions include ocular melanoma, hemangioma, cancers from other parts of the body which spread to the eye, Coats' disease, retinoblastoma, iris tumors (melanoma, cysts, metastatic lesions) and tumors of the conjunctiva including melanoma, and squamous cells carcinoma. He also manages the eye related side effects of chemotherapy treatments. He is an expert in using the most advanced diagnostic tests to make a personalized treatment plan for every patient. With his expertise in retinal surgery, he treats patients with a variety of advanced techniques including small instrument tumor biopsy, vitrectomy and radiation therapy.

As a retinal surgeon, he manages complicated retinal diseases including retinal detachment, macular holes, epiretinal membranes and diabetic eye disease.

His approach to any patient is to provide customized care for every patient and works closely with other experts at the Stanford Cancer Institute. Dr. Mruthyunjaya is actively involved in research in ocular cancer imaging, genetics and new modalities of tumor biopsy.

His passion lies in developing collaborative research networks and training the next generation of vitreoretinal surgeons. His academic contributions were recognized by the Heed, AOS-Knapp and Ronald G Michels foundations the American Society of Retina Specialists with a Senior Honor Award. He was recently listed as one of the worlds 150 most innovative retinal specialists.



Work and Education

Professional Education

Albany Medical College, Albany, NY, 06/30/1996


University of Rochester, Rochester, NY, 6/29/1997


Duke University Eye Center, Durham, NC, 6/30/2000


Duke University Eye Center, Durham, NC, UK, 6/30/2004

Moorfields Eye Hospital, London, 6/30/2005

Board Certifications

Ophthalmology, American Board of Ophthalmology

Conditions Treated

Ocular oncology

Retinal and Intraocular Tumors


Vitreoretinal surgery

All Publications

Anterior Chamber Angle Invasion of Iridociliary Melanoma. Ophthalmology Walter, S. D., Cummings, T. J., Mruthyunjaya, P. 2017; 124 (6): 842-?

View details for DOI 10.1016/j.ophtha.2016.12.003

View details for PubMedID 28528829

Association between Tumor Regression Rate and Gene Expression Profile after Iodine 125 Plaque Radiotherapy for Uveal Melanoma. Ophthalmology Mruthyunjaya, P., Seider, M. I., Stinnett, S., Schefler, A. 2017


Gene expression profile (GEP) testing segregates uveal melanoma (UM) into 2 main prognostic classes. It is unknown if a greater tumor regression response after iodine 125 (I(125)) brachytherapy correlates with class 2 GEP status. The purpose of this study was to determine whether there is a significant relationship between the rate of UM height regression and GEP classification testing after I(125) plaque brachytherapy.Multicenter, retrospective cohort study.Adult UM patients treated with I(125) plaque brachytherapy who had concurrent tumor biopsy at the time of surgery with a GEP test result from January 1, 2010 through June 30,2014.Baseline clinical data and GEP class assignments were obtained. The ultrasonographic tumor height was recorded at baseline and at 3, 6, 9, and 12 months and at the most recent final follow-up visits. Subanalysis of paired cases based on pretreatment ultrasound height was performed. Statistical analysis was performed using Wilcoxon rank-sum tests, the Fisher exact test, and Kaplan-Meier analysis.Percentage change in tumor height from baseline.A total of 353 patients were included in the study. Median follow-up was 2.1 years (range, 0.5-5.3 years). Gene expression profile status was class 1 in 247 tumors (70%) and class 2 in 106 tumors (30%). Increased patient age, larger tumor dimensions, and greater tumor thickness were associated with class 2 GEP status (P= 0.006, P < 0.001, and P < 0.001, respectively). The percentage reduction in tumor height from baseline was significantly greater in class 1 than class 2 tumors at 3 months (17.5% vs. 11.8%; P= 0.007) and 6 months (26.8% vs. 17.1%; P= 0.007), respectively, but there was no significant difference in reduction between class 1 and 2 tumors at 9 months (P= 0.26) and 12 months (P= 0.57) after treatment. Class 1A and 1B tumors showed similar reduction compared with class 2 tumors (P < 0.05).Class 1 UM tumors tend to regress more rapidly than class 2 tumors in the first 6 months after plaque radiotherapy. Class 1A and 1B tumors regress at similar rates after plaque radiotherapy.

View details for DOI 10.1016/j.ophtha.2017.04.013

View details for PubMedID 28549517

Outcomes of 27-Gauge Vitrectomy-Assisted Choroidal and Subretinal Biopsy. Ophthalmic surgery, lasers & imaging retina Grewal, D. S., Cummings, T. J., Mruthyunjaya, P. 2017; 48 (5): 406-415


To report the initial experience of 27-gauge vitrectomy-assisted choroidal and subretinal biopsy PATIENTS AND METHODS: Retrospective, interventional case series. Eighteen eyes of 18 patients undergoing 27-gauge vitrectomy-assisted choroidal (n = 16) or subretinal biopsy (n = 2). Clinical and lesion characteristics, cytopathology, histology, gene expression profiling (GEP), visual acuity (VA), complications including vitreous hemorrhage (VH), development of rhegmatogenous retinal detachment (RD), and need for additional surgeries were analyzed.Indications were choroidal melanoma (n = 10), indeterminate choroidal (n = 5), and subretinal lesions (n = 3). Mean lesion height was 3.33 mm 1.55 mm (range: 0.80 mm to 6.75 mm) and largest diameter was 8.63 mm 4.14 mm (range: 3 mm to 15.5 mm). Mean number of intralesional biopsy passes required was 1.76 0.83 (range: one to four). During a mean follow-up of 7.4 months 2.7 months (range: 4 months to 14 months), VA was unchanged (0.5 logMAR 0.6 logMAR vs. 0.7 logMAR 0.84 logMAR; P = .07). Pathologic diagnosis was obtained in 16 of 18 eyes (88.9%), and GEP data were collected for all 11 choroidal melanomas. Post-biopsy VH occurred in 13 of 18 eyes (72.2%) and was severe enough to require a concurrent limited vitrectomy in six eyes (33.3%). These eyes had a greater lesion height compared to eyes not requiring a vitrectomy (4.08 mm 1.68 mm vs. 2.76 mm 1.43 mm; P = .04). A rhegmatogenous RD requiring repeat surgery developed in two of 18 eyes (11.1%).The authors concluded that 27-gauge vitrectomy-assisted choroidal and subretinal biopsy established a diagnosis in 88.9% of eyes in lesions 0.8 mm or larger. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:406-415.].

View details for DOI 10.3928/23258160-20170428-07

View details for PubMedID 28499052

Comparison of Visual Outcomes in Coats' Disease: A 20-Year Experience. Ophthalmology Ong, S. S., Buckley, E. G., McCuen, B. W., Jaffe, G. J., Postel, E. A., Mahmoud, T. H., Stinnett, S. S., Toth, C. A., Vajzovic, L., Mruthyunjaya, P. 2017


To report differences in visual acuities among patients with Coats' disease who sought treatment at a tertiary care university-based practice.Single-center retrospective cohort study.Patients with Coats' disease diagnosed clinically, angiographically, or both from 1995 through2015.Patients were divided into 2 groups based on date of presentation: decade 1 (1995-2005) and decade 2 (2006-2015).Visual acuity (VA).Thirty-nine eyes of 39 patients were included with 19 eyes presenting in decade 1 and 20 eyes presenting in decade 2. Three patients demonstrated bilateral disease, but only the worse eye was included for analysis. Forty-seven percent of eyes in decade 1 demonstrated advanced stages of disease (stage 3B or worse) compared with 20% of eyes in decade 2. There was a trend for the mean initial presenting VA (standard deviation) for decade 1 eyes to be worse (2.051.29 logarithm of the minimum angle of resolution [logMAR]) than for decade 2 eyes (1.450.99 logMAR; P= 0.1). From initial to final follow-up visit, mean VA also worsened for decade 1 eyes (P= 0.03), but remained stable for decade 2 eyes (P= 1.0). At the end of follow-up, there was a trend for mean VA for decade 1 eyes (2.281.17 logMAR) to be worse than for decade 2 eyes (1.601.15 logMAR; P= 0.07). Eight eyes were observed initially in decade 1 compared with 1 eye in decade 2, and only 1 of the observed eyes (in decade 2) developed painful glaucoma requiring enucleation. Decade 2 eyes had a higher average number of procedures per eye (6.54.9) compared with decade 1 eyes (1.41.7; P < 0.001).The earlier presentation of disease in decade 2 suggests improvements in disease detection over time. Furthermore, there was a trend for eyes to have better final VA in this decade. This is due to acombination of factors, including earlier presentation of disease, fewer eyes being observed without treatment,and eyes, when treated, receiving a higher number of procedures.

View details for DOI 10.1016/j.ophtha.2017.03.051

View details for PubMedID 28461016

Pigmented Iridociliary Lesion and Increased Intraocular Pressure. JAMA ophthalmology Schwartz, T. M., Walter, S. D., Mruthyunjaya, P. 2017

View details for DOI 10.1001/jamaophthalmol.2016.5128

View details for PubMedID 28448661

Intraoperative 4-Dimensional Microscope-Integrated Optical Coherence Tomography-Guided 27-Gauge Transvitreal Choroidal Biopsy for Choroidal Melanoma RETINA-THE JOURNAL OF RETINAL AND VITREOUS DISEASES Grewal, D. S., Bhullar, P. K., Pasricha, N. D., Carrasco-Zevallos, O. M., Viehland, C., Keller, B., Shen, L., Izatt, J. A., Kuo, A. N., Toth, C. A., Mruthyunjaya, P. 2017; 37 (4): 796-799
Ocular Surface Epithelial Atypia Mimicking Squamous Neoplasia in Association With Ulcerative Colitis. Cornea Ong, S. S., Walter, S. D., Chen, X., Vora, G. K., Daluvoy, M., Proia, A. D., Mruthyunjaya, P. 2017; 36 (4): 502-505


Inflammatory bowel disease may be associated with extraintestinal manifestations. We report a case of severe reactive epithelial atypia resembling ocular surface squamous neoplasia (OSSN) in a patient with ulcerative colitis (UC).Case report.A 32-year-old woman presented with sequential, progressive keratoconjunctival lesions in the left and right eyes, and both lesions were excised. Anterior segment optical coherence tomography demonstrated features similar to OSSN, whereas histological examination revealed severe reactive epithelial atypia mimicking severe dysplasia. Shortly after treatment of the second eye, the patient was diagnosed with UC. Residual disease improved dramatically in response to systemic corticosteroids.Severe ocular surface epithelial atypia resembling OSSN may be seen in association with UC.

View details for DOI 10.1097/ICO.0000000000001144

View details for PubMedID 28129293

Diagnosis and Treatment of Acute Retinal Necrosis: A Report by the American Academy of Ophthalmology. Ophthalmology Schoenberger, S. D., Kim, S. J., Thorne, J. E., Mruthyunjaya, P., Yeh, S., Bakri, S. J., Ehlers, J. P. 2017; 124 (3): 382-392


To evaluate the available evidence in peer-reviewed publications about the diagnosis and treatment of acute retinal necrosis (ARN).Literature searches of the PubMed and Cochrane Library databases were last conducted on July 27, 2016. The searches identified 216 unique citations, and 49 articles of possible clinical relevance were reviewed in full text. Of these 49 articles, 27 were deemed sufficiently relevant or of interest, and they were rated according to strength of evidence. An additional 6 articles were identified from the reference lists of these articles and included. All 33 studies were retrospective.Polymerase chain reaction (PCR) testing of aqueous or vitreous humor was positive for herpes simplex virus (HSV) or varicella zoster virus (VZV) in 79% to 100% of cases of suspected ARN. Aqueous and vitreous specimens are both sensitive and specific. There is level II and III evidence supporting the use of intravenous and oral antiviral therapy for the treatment of ARN. Data suggest that equivalent plasma drug levels of acyclovir can be achieved after administration of oral valacyclovir or intravenous acyclovir. There is level II and III evidence suggesting that the combination of intravitreal foscarnet and systemic antiviral therapy may have greater therapeutic efficacy than systemic therapy alone. The effectiveness of prophylactic laser or early pars plana vitrectomy (PPV) in preventing retinal detachment (RD) remains unclear.Polymerase chain reaction testing of ocular fluid is useful in supporting a clinical diagnosis ofARN, but treatment should not be delayed while awaiting PCR results. Initial oral or intravenous antiviral therapy is effective in treating ARN. The adjunctive use of intravitreal foscarnet may be more effective than systemic therapy alone. The role of prophylactic laser retinopexy or early PPV is unknown at this time.

View details for DOI 10.1016/j.ophtha.2016.11.007

View details for PubMedID 28094044

Association of Pediatric Choroidal Neovascular Membranes at the Temporal Edge of Optic Nerve and Retinochoroidal Coloboma AMERICAN JOURNAL OF OPHTHALMOLOGY Grewal, D. S., Du Tran-Viet, D., Vajzovic, L., Mruthyunjaya, P., Toth, C. A. 2017; 174: 104-112
Advances in the management of conjunctival melanoma SURVEY OF OPHTHALMOLOGY Vora, G. K., Demirci, H., Marr, B., Mruthyunjaya, P. 2017; 62 (1): 26-42


Malignant melanoma of the conjunctiva is a rare but serious condition. Over the last several years, there have been important advances in the classification, diagnosis, and treatment of this condition. Recent cytogenetic and immunohistochemical studies are increasing understanding of its tumorigenesis. Diagnosis, although still made via histopathology, has been aided with imaging techniques such as ultrasound biomicroscopy and anterior segment optical coherence tomography. Primary treatment consists of surgical excision. But adjuvant treatments with cryotherapy, topical chemotherapy, and radiation therapy have shown increased success. Sentinel lymph node biopsy has shown early promise of detecting micro-metastasis. Long term follow-up of patients with conjunctival melanoma with systemic surveillance is necessary to detect recurrences and metastases.

View details for DOI 10.1016/j.survophthal.2016.06.001

View details for Web of Science ID 000389617200002

View details for PubMedID 27321895

Association of Pediatric Choroidal Neovascular Membranes at the Temporal Edge of Optic Nerve and Retinochoroidal Coloboma. American journal of ophthalmology Grewal, D. S., Tran Viet, D., Vajzovic, L., Mruthyunjaya, P., Toth, C. A. 2016


To describe the characteristics of pediatric choroidal neovascular membranes (CNV) associated with retinochoroidal and optic nerve coloboma using optical coherence tomography (OCT) and their response to treatment.Retrospective case series.Retrospective review of children <16 years with CNV and retinochoroidal and optic-nerve coloboma from 1995-2015 who underwent OCT imaging using either hand-held (Bioptigen, Morrisville, NC) or table-top OCT (Spectralis, Heidelberg, Carlsbad, CA) RESULTS: Eight eyes of 8 patients (3 males, 5 females) with a mean age of 4.13.9 years (range 6-months to 10-years) at diagnosis were included. Mean follow-up was 21.412.1 months (range 7-38 months). An optic-nerve coloboma was present in 2 eyes and combined optic nerve and retinochoroidal coloboma in 6 eyes. In all eyes, CNV was located at temporal margin of the coloboma closest to macula. Fluorescein angiogram characteristics included staining without leakage suggesting inactivity (n=6), and leakage (n=2). OCT characteristics included subretinal fluid (n=5), intraretinal fluid and cysts (n=1) and subretinal hyperreflective material (n=7). Two eyes received intravitreal bevacizumab (range 3-6) injections, and one of which also underwent focal peripapillary laser. Both eyes showed improvement in subretinal or intraretinal fluid on OCT. Vision at presentation among those quantified, ranged from 20/200 to 20/40 and at final follow-up from 20/400 to 20/30. Genetic or systemic abnormalities were seen in 6 patients.Association of pediatric CNV occurrence at the temporal margin of retinochoroidal and optic nerve colobomas closest to fovea has not been established before and careful OCT and angiographic assessment of this region is warranted. The CNV lesions exhibit a varied degree of response to treatment.

View details for DOI 10.1016/j.ajo.2016.10.010

View details for PubMedID 27793604

Wide field of view swept-source optical coherence tomography for peripheral retinal disease BRITISH JOURNAL OF OPHTHALMOLOGY McNabb, R. P., Grewal, D. S., Mehta, R., Schuman, S. G., Izatt, J. A., Mahmoud, T. H., Jaffe, G. J., Mruthyunjaya, P., Kuo, A. N. 2016; 100 (10): 1377-1382


To assess peripheral retinal lesions and the posterior pole in single widefield optical coherence tomography (OCT) volumes.A wide field of view (FOV) swept-source OCT (WFOV SSOCT) system was developed using a commercial swept-source laser and a custom sample arm consisting of two indirect ophthalmic lenses. Twenty-seven subjects with peripheral lesions (choroidal melanomas, choroidal naevi, sclerochoroidal calcification, retinitis pigmentosa, diabetic retinopathy, retinoschisis and uveitis) were imaged with the WFOV SSOCT. Volumes were taken in primary gaze. Using the optic nerve to fovea distance as a reference measurement, comparisons were made between the lateral FOV of the WFOV SSOCT, current generation spectral-domain OCT (SDOCT) and widefield scanning laser ophthalmoscopy (SLO) of the same eyes.Peripheral pathologies were captured with WFOV SSOCT in 26 of the 27 subjects. The one not captured was in the far nasal periphery and was not seen in the primary gaze volume. Posterior pole associated pathologies were captured in all subjects. Current generation SDOCT had a mean lateral FOV of 2.080.21 optic nerve to fovea distance units, WFOV SSOCT had an FOV of 4.620.62 units and SLO had an FOV of 9.351.02 units.WFOV OCT can be used to examine both peripheral retinal pathology and the posterior pole within a single volume acquisition. SLO had the greatest FOV, but does not provide depth information. Future studies using widefield OCT systems will help further delineate the role of WFOV OCT to quantitatively assess and monitor peripheral retinal disease in three dimensions.

View details for DOI 10.1136/bjophthalmol-2015-307480

View details for Web of Science ID 000384679400013

View details for PubMedID 26755643

Portable Optical Coherence Tomography Detection or Confirmation of Ophthalmoscopically Invisible or Indeterminate Active Retinoblastoma. Ophthalmic surgery, lasers & imaging retina Seider, M. I., Grewal, D. S., Mruthyunjaya, P. 2016; 47 (10): 965-968


Portable, hand-held optical coherence tomography (OCT) revealed three clinically relevant yet not ophthalmoscopically detected or confirmed manifestations of retinoblastoma in a single patient with familial bilateral disease. Specifically, OCT showed new retinal tumors, new vitreous seeds, and tumor recurrence before they could be detected or confirmed by ophthalmoscopy. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:965-968.].

View details for DOI 10.3928/23258160-20161004-12

View details for PubMedID 27759865

Intraoperative 4-Dimensional Microscope-Integrated Optical Coherence Tomography-Guided 27-Gauge Transvitreal Choroidal Biopsy for Choroidal Melanoma. Retina (Philadelphia, Pa.) Grewal, D. S., Bhullar, P. K., Pasricha, N. D., Carrasco-Zevallos, O. M., Viehland, C., Keller, B., Shen, L., Izatt, J. A., Kuo, A. N., Toth, C. A., Mruthyunjaya, P. 2016: -?

View details for PubMedID 27673716

Primary adenocarcinoma of pigmented ciliary epithelium in a phthisical eye SURVEY OF OPHTHALMOLOGY Kumar, J. B., Proia, A. D., Mruthyunjaya, P., Sharma, S. 2016; 61 (4): 502-505


We report a case of adenocarcinoma of the pigmented ciliary epithelium arising in a phthisical eye. A 92-year-old man who initially presented with severe ocular pain had calcification extending from the posterior pole to ciliary body on B-scan ultrasonography to a degree not previously reported. We highlight the importance of screening for intraocular neoplasms in adults with a long-standing phthisical eye.

View details for DOI 10.1016/j.survophthal.2015.11.001

View details for Web of Science ID 000378444500009

View details for PubMedID 26597037

Impact of Microscope-Integrated OCT on Ophthalmology Resident Performance of Anterior Segment Surgical Maneuvers in Model Eyes INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Todorich, B., Shieh, C., Desouza, P. J., Carrasco-Zevallos, O. M., Cunefare, D. L., Stinnett, S. S., Izatt, J. A., Farsiu, S., Mruthyunjaya, P., Kuo, A. N., Toth, C. A. 2016; 57 (9): OCT146-OCT153


The integration of swept-source optical coherence tomography (SS-OCT) into the operating microscope enables real-time, tissue-level three-dimensional (3D) imaging to aid in ophthalmic microsurgery. In this prospective randomized controlled study, we evaluated the impact of SS microscope-integrated OCT (MI-OCT) on ophthalmology residents' performance of ophthalmic microsurgical maneuvers.Fourteen ophthalmology residents from a single institution were stratified by year of training and randomized to perform four anterior segment surgical maneuvers on porcine eyes with (MI-OCT+) or without (MI-OCT-) direct intraoperative OCT guidance. Subsequently, both groups repeated the same maneuvers without MI-OCT feedback to test whether initial MI-OCT experience affected subsequent surgical performance. Finally, the MI-OCT- group was crossed over and allowed to repeat the same maneuvers with direct MI-OCT guidance. Each resident completed a survey at the completion of the study.With direct MI-OCT feedback, residents demonstrated enhanced performance in depth-based anterior segment maneuvers (corneal suture passes at 50% and 90% depth and corneal laceration repair) compared with the residents operating without MI-OCT. Microscope-integrated OCT+ residents continued to outperform the controls when both groups subsequently operated without MI-OCT. For clear corneal wound geometry, there was no statistically significant effect of MI-OCT as applied in this study. Overall, the resident surgeons rated their subjective experience of using MI-OCT very favorably.Microscope-integrated OCT feedback enhances performance of ophthalmology residents in select anterior segment surgical maneuvers. Microscope-integrated OCT represents a valuable tool in the surgical education of ophthalmology residents.

View details for DOI 10.1167/iovs.15-18818

View details for Web of Science ID 000383985400008

View details for PubMedID 27409466

Scleral Buckling with Chandelier Illumination. Journal of ophthalmic & vision research Seider, M. I., Nomides, R. E., Hahn, P., Mruthyunjaya, P., Mahmoud, T. H. 2016; 11 (3): 304-309


Scleral buckling is a highly successful technique for the repair of rhegmatogenous retinal detachment that requires intra-operative examination of the retina and treatment of retinal breaks via indirect ophthalmoscopy. Data suggest that scleral buckling likely results in improved outcomes for many patients but is declining in popularity, perhaps because of significant advances in vitrectomy instrumentation and visualization systems. Emerging data suggest that chandelier-assisted scleral buckling is safe and has many potential advantages over traditional buckling techniques. By combining traditional scleral buckling with contemporary vitreoretinal visualization techniques, chandelier-assistance may increase the popularity of scleral buckling to treat primary rhegmatogenous retinal detachment for surgeons of the next generation, maintaining buckling as an option for appropriate patients in the future.

View details for DOI 10.4103/2008-322X.188402

View details for PubMedID 27621789

MULTICOLOR IMAGING OF INNER RETINAL ALTERATIONS AFTER INTERNAL LIMITING MEMBRANE PEELING. Retinal cases & brief reports Feng, H. L., Sharma, S., Asrani, S., Mruthyunjaya, P. 2016: -?


To characterize the appearance of inner retinal alterations after internal limiting membrane (ILM) peeling using multicolor confocal scanning laser ophthalmoscopy (cSLO).Retrospective review of two eyes that underwent pars plana vitrectomy with internal limiting membrane peeling and postoperative multicolor cSLO with spectral-domain optical coherence tomography. Infrared, green, blue, standard multicolor, and blue-green enhanced multicolor reflectance images were evaluated alongside spectral-domain optical coherence tomography for inner retinal alterations.Two eyes of 2 patients, aged 70 and 65 years, were identified. Preoperative diagnoses were epiretinal membrane with lamellar macular hole for Case 1 and full-thickness macular hole for Case 2. Time from surgery to initial multicolor cSLO imaging was 9 years in Case 1 and 3 weeks in Case 2. Inner retinal alterations were best visualized on blue reflectance, moderately visualized on green and blue-green enhanced multicolor, and less evident on infrared and standard multicolor. In Case 2, serial multicolor cSLO imaging demonstrated the emergence of inner retinal alterations between 3 weeks and 5 weeks postoperatively.Multicolor cSLO is a novel imaging modality capable of detecting inner retinal alterations in patients with a history of internal limiting membrane peeling, and may be clinically useful for monitoring anatomical changes associated with internal limiting membrane peeling.

View details for PubMedID 27164506



To compare functional and anatomical outcomes and complication rates between valved versus traditional nonvalved small-gauge cannula vitrectomy for retinal detachment repair.Retrospective case series of 163 eyes undergoing small-gauge valved versus nonvalved vitrectomy with intraoperative perfluoro-n-octane for retinal detachment repair at a single academic institution.There were 104 eyes in the valved cannula group and 59 eyes in the nonvalved cannula group. The valved group had lower baseline Grade C proliferative vitreoretinopathy (35 vs. 53%, P = 0.031) and combined rhegmatogenous retinal detachment/tractional retinal detachment (3 vs. 12%, P = 0.037), but both groups had otherwise comparable preoperative characteristics. Final postoperative best-corrected visual acuity was 1.01 logarithm of the minimum angle of resolution (Snellen 20/205) and 1.27 (Snellen 20/372) (P = 0.131) in valved and nonvalved cannula eyes, respectively. Single surgery success was equivalent between the valved and nonvalved groups (88 vs. 86%; P = 1.00). Final anatomical success was higher in the valved versus nonvalved group (98 vs. 90%; P = 0.027). Complication rates were not statistically different, including Postoperative Day 1 intraocular pressure, Postoperative Day 1 anterior chamber fibrin, retained subretinal/intraocular perfluoro-n-octane, and epiretinal membrane peeling.Valved cannulas, with their improved fluidics, are an important addition to pars plana vitrectomy with similar functional and anatomical success without increased complication rates compared with traditional nonvalved cannulas.

View details for DOI 10.1097/IAE.0000000000000762

View details for Web of Science ID 000373884700012

View details for PubMedID 26398696

Outcomes in Eyes with Retinal Angiomatous Proliferation in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) OPHTHALMOLOGY Daniel, E., Shaffer, J., Ying, G., Grunwald, J. E., Martin, D. F., Jaffe, G. J., Maguire, M. G. 2016; 123 (3): 609-616


To compare baseline characteristics, visual acuity (VA), and morphologic outcomes between eyes with retinal angiomatous proliferation (RAP) and all other eyes among patients with neovascular age-related macular degeneration (NVAMD) treated with anti-vascular endothelial growth factor (VEGF) drugs.Prospective cohort study within the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).Patients with NVAMD.Reading center staff evaluated digital color fundus photographs, fluorescein angiography (FA) images, and optical coherence tomography (OCT) scans of eyes with NVAMD treated with either ranibizumab or bevacizumab over a 2-year period. Retinal angiomatous proliferation was identified by the intense intra-retinal leakage of fluorescein in combination with other associated features.Visual acuity; fluorescein leakage; scar; geographic atrophy (GA) on FA; retinal thickness, fluid, and subretinal hyperreflective material (SHRM) on OCT; and the number of intravitreal anti-VEGF injections at 1 and 2 years.Retinal angiomatous proliferation was present in 126 of 1183 (10.7%) study eyes at baseline. Mean VA improvement from baseline was greater (10.6 vs. 6.9 letters; P = 0.01) at 1 year, but similar at 2 years (7.8 vs. 6.2 letters; P = 0.34). At 1 year, eyes with RAP were more likely to have no fluid (46% vs. 26%; P < 0.001) on OCT, no leakage on FA (61% vs. 50%; P = 0.03), and greater reduction in foveal thickness (-240 m vs. -161 m; P < 0.001). They were more likely to demonstrate GA (24% vs. 15%; P = 0.01) and less likely to have scarring (17% vs. 36%; P < 0.001) or SHRM (36% vs. 48%; P = 0.01). These results were similar at 2 years. The mean change in lesion size at 1 year differed (-0.27 DA vs. 0.27 DA; P = 0.02), but was similar at 2 years (0.49 DA vs. 0.79 DA; P = 0.26). Among eyes treated PRN, eyes with RAP received a lower mean number of injections in year 1 (6.1 vs. 7.4; P = 0.003) and year 2 (5.4 vs. 6.6; P = 0.025).At both 1 and 2 years after initiation of anti-VEGF treatment in CATT, eyes with RAP were less likely to have fluid, FA leakage, scar, and SHRM and more likely to have GA than eyes without RAP. Mean improvement in VA was similar at 2 years.

View details for DOI 10.1016/j.ophtha.2015.10.034

View details for Web of Science ID 000370626300036

View details for PubMedID 26681392

A Comparative Study of Rebound Tonometry With Tonopen and Goldmann Applanation Tonometry Following Vitreoretinal Surgery AMERICAN JOURNAL OF OPHTHALMOLOGY Grewal, D. S., Stinnett, S. S., Folgar, F. A., Schneider, E. W., Vajzovic, L., Asrani, S., Freedman, S. F., Mruthyunjaya, P., Hahn, P. 2016; 161: 22-28


To investigate agreement in intraocular pressure (IOP) measurements among Icare rebound tonometry, Tonopen tonometry, and Goldmann applanation tonometry following vitreoretinal surgery.Reliability analysis of tonometers.Fifty-eyes of 50 adults undergoing vitreoretinal surgery were enrolled. IOP was measured on first postoperative day using Icare (Tiolat, Helsinki, Finland), followed by Tonopen (Reichert, Depew, New York, USA) and Goldmann (Haag-Streit USA, Mason, Ohio, USA) in randomized order. Intraclass correlation coefficients (ICC) and Bland-Altman plots were calculated for all subcategories.Icare successfully measured IOP in all eyes, while Goldmann was unmeasurable in 6 eyes (12%) and Tonopen in 1 eye (2%). Mean IOP by Icare, Tonopen, and Goldmann was 15.9 8.9, 16.9 6.2, and 16.0 7.3 mm Hg, respectively (P = .76). Type of intraocular tamponade, status of lens, status of cornea, gauge of instrumentation, and history of prior vitrectomy did not result in significant differences among the 3 tonometers. ICC was excellent (>0.75) in all subgroups, except at IOP <10 and 23 mm Hg (based on Icare). In eyes with IOP <10 mm Hg, Icare underestimated IOP (mm Hg; P = .01) compared to Goldmann (2.0 2.1) and Tonopen (3.5 2.4), whereas at IOP 23 mm Hg Icare was overestimated (P = .01) compared to Goldmann (3.77 3.49) and Tonopen (4.97 3.33). Overall, differences in IOP were 3 mm Hg in 58% of eyes for Icare-Tonopen, 72% for Tonopen-Goldmann, and 62% for Icare-Goldmann.IOP measurements using Icare rebound tonometry, Tonopen, and Goldmann tonometry are in excellent agreement following vitreoretinal surgery. However, Icare overestimates at IOP 23 and underestimates at IOP <10 mm Hg.

View details for DOI 10.1016/j.ajo.2015.09.022

View details for Web of Science ID 000367632300004

View details for PubMedID 26408266

Incidence, Risk Factors, and Timing of Elevated Intraocular Pressure After Intravitreal Triamcinolone Acetonide Injection for Macular Edema Secondary to Retinal Vein Occlusion SCORE Study Report 15 JAMA OPHTHALMOLOGY Aref, A. A., Scott, I. U., Oden, N. L., Ip, M. S., Blodi, B. A., VanVeldhuisen, P. C. 2015; 133 (9): 1022-1029


The Standard of Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) Study showed that intravitreal triamcinolone acetonide (IVTA) is effective at reducing macular edema and improving visual acuity in participants with retinal vein occlusion. Secondary analysis of the incidence, risk factors, and timing of intraocular pressure (IOP) elevation occurring after IVTA provides guidance for clinical decision making and management of patients treated with IVTA.To investigate the incidence, risk factors, and time course of IOP elevation in participants in the SCORE Study.Secondary analysis conducted from August through December 2014 of a prospective, randomized clinical trial featuring an evaluable population conducted at 75 clinical sites. Six hundred eighty-two patients with macular edema secondary to retinal vein occlusion were enrolled in the study. The SCORE Study enrollment period ran from November 4, 2004, to February 29, 2008, with participant follow-up ending February 28, 2009.Study participants were randomized to standard of care, 1 mg of IVTA, or 4 mg of IVTA therapy and followed up for a mean (SD) of 24.7 (10.3) months.Intraocular pressure elevation greater than 10 mm Hg from baseline.Kaplan-Meier incidences of IOP elevation greater than 10 mm Hg from baseline at 36 months were 0.02 (95% CI, 0.01-0.06), 0.09 (95% CI, 0.05-0.14), and 0.45 (95% CI, 0.38-0.53) in the standard of care, 1-mg IVTA, and 4-mg IVTA groups, respectively. The rates of IOP-related events were higher for the 4-mg IVTA group compared with the other groups (P.001 for main outcome measure). Younger age, 4-mg IVTA vs 1-mg IVTA treatment, and higher baseline IOP were found to confer greater risk for IOP-related events (P<.05 for all). The median number of days from time of first injection to IOP elevation greater than 10 mm Hg from baseline was 34.0 and 52.5 days in participants treated with 1-mg and 4-mg IVTA, respectively.Intravitreal triamcinolone acetonide injection therapy, in particular the 4-mg dose, is associated with an increased risk for IOP elevation. The risk factors for an IOP-related event include higher treatment dose, younger age, and higher baseline IOP. Intraocular pressure-related events may take several months from the time of first IVTA injection to occur. Clinicians should be mindful of these risk factors when assessing the risks and benefits of IVTA therapy and also of the need for long-term follow-up of participants at risk for this Identifier: NCT00105027.

View details for DOI 10.1001/jamaophthalmol.2015.1823

View details for Web of Science ID 000361377100010

View details for PubMedID 26086920

Subretinal Hyperreflective Material in the Comparison of Age-Related Macular Degeneration Treatments Trials OPHTHALMOLOGY Willoughby, A. S., Ying, G., Toth, C. A., Maguire, M. G., Burns, R. E., Grunwald, J. E., Daniel, E., Jaffe, G. J. 2015; 122 (9): 1846-?


To evaluate the association of subretinal hyperreflective material (SHRM) with visual acuity (VA), geographic atrophy (GA), and scar in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).Prospective cohort study within a randomized clinical trial.The 1185 CATT participants.Masked readers graded scar and GA on fundus photography and fluorescein angiography and graded SHRM on time-domain and spectral-domain (SD) optical coherence tomography (OCT) throughout 104 weeks. Measurements of SHRM height and width in the fovea, within the center 1 mm(2), or outside the center 1mm(2) were obtained on SD OCT images at 56 (n= 76) and 104 (n= 66) weeks.Presence of SHRM, as well as location and size, and associations with VA, scar, and GA.Among CATT participants, the percentage with SHRM at enrollment was 77%, decreasing to 68% at 4 weeks after treatment and to 54% at 104 weeks. At 104 weeks, scar was present more often in eyes with persistent SHRM than in eyes with SHRM that resolved (64% vs. 31%; P < 0.0001). Among eyes with detailed evaluation of SHRM at weeks 56 (n= 76) and 104 (n= 66), mean VA letter score was 73.5 (standard error [SE], 2.8), 73.1 (SE, 3.4), 65.3 (SE, 3.5), and 63.9 (SE, 3.7) when SHRM was absent, present outside the central 1 mm(2), present within the central 1 mm(2) but not the foveal center, or present at the foveal center (P= 0.02), respectively. When SHRM was present, the median maximum height under the fovea, within the central 1 mm(2) including the fovea and anywhere within the scan, was 86 m, 120 m, and 122 m, respectively. Visual acuity was decreased with greater SHRM height and width (P < 0.05).In eyes with neovascular age-related macular degeneration (AMD), SHRM is common and often persists after anti-vascular endothelial growth factor treatment. At 2 years, eyes with scar were more likely to have SHRM than other eyes. Greater SHRM dimensions were associated with worse VA. In eyes with neovascular AMD, SHRM is an important morphologic biomarker.

View details for DOI 10.1016/j.ophtha.2015.05.042

View details for Web of Science ID 000360116900025

View details for PubMedID 26143666

Retained Intraocular Perfluoro-n-octane After Valved Cannula Pars Plana Vitrectomy for Retinal Detachment OPHTHALMIC SURGERY LASERS & IMAGING RETINA Oellers, P., Schneider, E. W., Fekrat, S., Mahmoud, T. H., Mruthyunjaya, P., Hahn, P. 2015; 46 (4): 451-456


To investigate cases of retained intraocular perfluoro-n-octane (PFO) after pars plana vitrectomy (PPV) for retinal detachment (RD).Retrospective, noncomparative case series of six eyes with retained intraocular PFO after RD repair. Clinical data were supplemented with an experimental silicone eye model.A cluster of six cases of retained intraocular PFO after PPV for RD repair were noted shortly after transitioning to valved cannulas. PFO was noted in the anterior chamber (AC) and/or vitreous and removed with AC paracentesis, AC wash-out, and/or PPV. A silicone eye model demonstrated that PFO levels are maintained anterior to cannula insertion with valved cannulas only.The authors hypothesize that anterior PFO fill using valved cannulas can lead to sequestration within the AC, zonules, ciliary sulcus, ciliary teeth, and/or capsular bag. They suggest vigilance in not overfilling PFO, particularly when transitioning to use of valved cannulas, to minimize the risk of intraocular retention.

View details for DOI 10.3928/23258160-20150422-08

View details for Web of Science ID 000359292300008

View details for PubMedID 25970866

Outcomes of Eyes with Lesions Composed of > 50% Blood in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) OPHTHALMOLOGY Altaweel, M. M., Daniel, E., Martin, D. F., Mittra, R. A., Grunwald, J. E., Lai, M. M., Melamud, A., Morse, L. S., Huang, J., Ferris, F. L., Fine, S. L., Maguire, M. G. 2015; 122 (2): 391-?


To compare baseline characteristics, treatment frequency, visual acuity (VA), and morphologic outcomes of eyes with >50% of the lesion composed of blood (B50 group) versus all other eyes (Other group) enrolled in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).Prospective cohort study within a multicenter randomized clinical trial.CATT patients with neovascular age-related macular degeneration (AMD).Treatment for the study eye was assigned randomly to either ranibizumab or bevacizumab and to 3 different dosing regimens over a 2-year period. Reading center graders evaluated baseline and follow-up morphology in color fundus photographs, fluorescein angiography (FA), and optical coherence tomography (OCT). Masked examiners tested VA.Morphologic features and VA at 1 and 2 years.The B50 group consisted of 84 of 1185 (7.1%) patients enrolled in CATT. Baseline lesion characteristics differed between groups. In the B50 group, choroidal neovascularization size was smaller (0.73 vs 1.83 disc areas [DA]; P < 0.001), total lesion size was greater (4.55 vs 2.31 DA; P <0.001), total retinal thickness was greater (524 vs 455 m; P= 0.02), and mean VA was worse (56.0 vs 60.9 letters; P= 0.002). Increases in mean VA were similar in the B50 and Other groups at 1 year (+9.3 vs+7.2 letters; P= 0.22) and at 2 years (9.0 vs 6.1 letters; P= 0.17). Eyes treated PRN received a similar number of injections in the 2 groups (12.2 vs 13.4; P=0.27). Mean lesion size in the B50 group decreased by 1.2 DA at both 1 and 2 years (primarily owing toresolution of hemorrhage) and increased in the Other group by 0.33 DA at 1 year and 0.91 DA at 2 years (P<0.001). Leakage on FA and fluid on OCT were similar between groups at 1 and 2 years.In CATT, the B50 group had a visual prognosis similar to the Other group. Lesion size decreased markedly through 2 years. Eyes like those enrolled in CATT with neovascular AMD lesions composed of >50% blood can be managed similarly to those with less or no blood.

View details for DOI 10.1016/j.ophtha.2014.08.020

View details for Web of Science ID 000348290000032

View details for PubMedID 25307130

Conjunctival Pseudotumor Caused by Herpes Simplex Virus Infection JAMA OPHTHALMOLOGY Vora, G. K., Marr, B., Cummings, T. J., Mruthyunjaya, P. 2015; 133 (1): 105-107
Conjunctival Melanoma JAMA OPHTHALMOLOGY Yiu, G., Cummings, T. J., Mruthyunjaya, P. 2014; 132 (12): 1432-1432

View details for Web of Science ID 000346176400009

View details for PubMedID 25340828

Comparison of Optical Coherence Tomography Assessments in the Comparison of Age-Related Macular Degeneration Treatments Trials OPHTHALMOLOGY Folgar, F. A., Jaffe, G. J., Ying, G., Maguire, M. G., Toth, C. A. 2014; 121 (10): 1956-?


To determine agreement between spectral-domain (SD) and time-domain (TD) optical coherence tomography (OCT) image assessments by certified readers in eyes treated for neovascular age-related macular degeneration (AMD).Cross-sectional study within the Comparison of AMD Treatments Trials (CATT).During year 2 of CATT, 1213 pairs of SD OCT and TD OCT scans were compared from a subset of 384 eyes.Masked readers independently graded OCT scans for presence of intraretinal fluid (IRF), subretinal fluid (SRF), and sub-retinal pigment epithelium (RPE) fluid and performed manual measurements of retinal, SRF, and subretinal tissue complex thicknesses at the foveal center.Presence of fluid was evaluated with percent agreement, coefficients with 95% confidence intervals (CIs), and McNemar tests. Thickness measurements were evaluated with mean difference () 95% limits of agreement and intraclass correlation coefficients (ICCs) with 95% CIs.Between SD OCT and TD OCT, agreement on presence of any fluid was 82% ( = 0.46; 95% CI, 0.40-0.52), with 5% more SD OCT scans demonstrating fluid (P<0.001). Agreement on presence of SRF was 87% and sub-RPE fluid was 80%, with more SD OCT scans demonstrating fluid (both P < 0.001). Agreement on IRF was 73% ( = 0.47; 95% CI, 0.42-0.52), with 6% more TD OCT scans demonstrating fluid (P < 0.001). Between SD OCT and TD OCT, mean thickness of the retina was = 567 m, SRF was = 1.535 m, and subretinal tissue complex was = 586 m. Thickness measurements were reproducible for retina (ICC = 0.84; 95% CI, 0.83-0.86), SRF (ICC = 0.88; 95% CI, 0.86-0.89), and subretinal tissue complex (ICC = 0.91; 95% CI, 0.89-0.92), with 25-m difference in these measurements in 71%, 94%, and 61% of paired scans, respectively.Agreement on fluid presence and manual thickness measurements between paired scans from each OCT modality was moderate, providing a reasonable basis to compare CATT results with future SD OCT-based trials. Fluid was detected 5% more frequently with SD OCT, which may increase frequency of fluid-based treatment. Lower-resolution and artifactual interpretation of dark areas as cystoid edema may explain the greater frequency of IRF detected with TD OCT.

View details for DOI 10.1016/j.ophtha.2014.04.020

View details for Web of Science ID 000342697300025

View details for PubMedID 24835760

Choroidal Metastatasis From a Neuroendocrine Tumor Masquerading as Choroidal Melanoma OPHTHALMIC SURGERY LASERS & IMAGING RETINA Yiu, G., Cummings, T. J., Mruthyunjaya, P. 2014; 45 (5): 456-458


A mushroom-shaped choroidal mass is classically suggestive of melanoma, due to the ability of these tumors to erupt through Bruch's membrane. In contrast, choroidal metastases rarely adopt this growth pattern. The authors present an unusual case of a patient with a large choroidal metastasis from a pancreatic neuroendocrine tumor that shows a collar-button configuration. The diagnosis was confirmed by histology and immunohistochemistry following enucleation. The authors review the typical appearance of choroidal metastases from neuroendocrine tumors and discuss mechanisms by which uveal tumors may extend through Bruch's membrane.

View details for DOI 10.3928/23258160-20140725-01

View details for Web of Science ID 000347297300016

View details for PubMedID 25153655



To compare 25-hydroxyvitamin D (25OHD) levels in patients with neovascular age-related macular degeneration (NVAMD) with patients with nonneovascular age-related macular degeneration and control patients.Medical records of all patients diagnosed with age-related macular degeneration and tested for serum 25OHD level at a single medical center were reviewed. Control patients were selected from patients diagnosed with pseudophakia but without age-related macular degeneration. The lowest 25OHD level available for each patient was recorded.Two hundred sixteen patients with nonneovascular age-related macular degeneration, 146 with NVAMD, and 100 non-age-related macular degeneration control patients were included. The levels of 25OHD (mean SD) were significantly lower in NVAMD patients (26.1 14.4 ng/mL) versus nonneovascular age-related macular degeneration (31.5 18.2 ng/mL, P = 0.003) and control (29.4 10.1 ng/mL, P = 0.049) patients. The prevalence of vitamin D insufficiency (<30 ng/mL 25OHD), deficiency (<20 ng/mL), and severe deficiency (<10 ng/mL) were highest in the NVAMD group. The highest quintile of 25OHD was associated with a 0.35 (95% confidence interval, 0.18-0.68) odds ratio for NVAMD.This is the largest study to compare 25OHD levels in patients with the different clinical forms of age-related macular degeneration. Mean 25OHD levels were lower and vitamin D deficiency was more prevalent in NVAMD patients. These associations suggest that further research is necessary regarding vitamin D deficiency as a potentially modifiable risk factor for the development of NVAMD.

View details for Web of Science ID 000341630400013

View details for PubMedID 24946100

Sporadic Visual Acuity Loss in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) AMERICAN JOURNAL OF OPHTHALMOLOGY Kim, B. J., Ying, G., Huang, J., Levy, N. E., Maguire, M. G. 2014; 158 (1): 128-135


To evaluate transient, large visual acuity (VA) decreases, termed sporadic vision loss, during anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration (AMD).Cohort within a randomized clinical trial.setting: Comparison of Age-Related Macular Degeneration Treatments Trials (CATT). study population: Total of 1185 CATT patients. main outcome measures: Incidence of sporadic vision loss and odds ratio (OR) for association with patient and ocular factors. Sporadic vision loss was a decline of 15 letters from the previous visit, followed by a return at the next visit to no more than 5 letters worse than the visit before the VA loss.There were 143 sporadic vision loss events in 122 of 1185 patients (10.3%). Mean VA at 2 years for those with and without sporadic vision loss was 58.5 (20/63) and 68.4 (20/40) letters, respectively (P < .001). Among patients treated pro re nata, no injection was given for 27.6% (27/98) of sporadic vision loss events. Multivariate analysis demonstrated that baseline predictors for sporadic vision loss included worse baseline VA (OR 2.92, 95% confidence interval [CI]:1.65-5.17 for 20/200 compared with 20/40), scar (OR 2.21, 95% CI:1.22-4.01), intraretinal foveal fluid on optical coherence tomography (OR 1.80, 95% CI:1.11-2.91), and medical history of anxiety (OR 1.90, 95% CI:1.12-3.24) and syncope (OR 2.75, 95% CI:1.45-5.22). Refraction decreased the likelihood of sporadic vision loss (OR 0.62, 95%CI: 0.42-0.91).Approximately 10% of CATT patients had sporadic vision loss. Baseline predictors included AMD-related factors and factors independent of AMD. These data are relevant for clinicians in practice and those involved in clinical trials.

View details for DOI 10.1016/j.ajo.2014.04.004

View details for Web of Science ID 000338097300018

View details for PubMedID 24727261

Uveal Melanoma Treated With Iodine-125 Episcleral Plaque: An Analysis of Dose on Disease Control and Visual Outcomes INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS Perez, B. A., Mettu, P., Vajzovic, L., Rivera, D., Alkaissi, A., Steffey, B. A., Cai, J., Stinnett, S., Dutton, J. J., Buckley, E. G., Halperin, E., Marks, L. B., Mruthyunjaya, P., Kirsch, D. G. 2014; 89 (1): 127-136


To investigate, in the treatment of uveal melanomas, how tumor control, radiation toxicity, and visual outcomes are affected by the radiation dose at the tumor apex.A retrospective review was performed to evaluate patients treated for uveal melanoma with (125)I plaques between 1988 and 2010. Radiation dose is reported as dose to tumor apex and dose to 5 mm. Primary endpoints included time to local failure, distant failure, and death. Secondary endpoints included eye preservation, visual acuity, and radiation-related complications. Univariate and multivariate analyses were performed to determine associations between radiation dose and the endpoint variables.One hundred ninety patients with sufficient data to evaluate the endpoints were included. The 5-year local control rate was 91%. The 5-year distant metastases rate was 10%. The 5-year overall survival rate was 84%. There were no differences in outcome (local control, distant metastases, overall survival) when dose was stratified by apex dose quartile (<69 Gy, 69-81 Gy, 81-89 Gy, >89 Gy). However, increasing apex dose and dose to 5-mm depth were correlated with greater visual acuity loss (P=.02, P=.0006), worse final visual acuity (P=.02, P<.0001), and radiation complications (P<.0001, P=.0009). In addition, enucleation rates were worse with increasing quartiles of dose to 5 mm (P=.0001).Doses at least as low as 69 Gy prescribed to the tumor apex achieve rates of local control, distant metastasis-free survival, and overall survival that are similar to radiation doses of 85 Gy to the tumor apex, but with improved visual outcomes.

View details for DOI 10.1016/j.ijrobp.2014.01.026

View details for Web of Science ID 000334590500019

View details for PubMedID 24613808

VEGFA and VEGFR2 Gene Polymorphisms and Response to Anti-Vascular Endothelial Growth Factor Therapy Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) JAMA OPHTHALMOLOGY Hagstrom, S. A., Ying, G., Pauer, G. J., Sturgill-Short, G. M., Huang, J., Maguire, M. G., Martin, D. F. 2014; 132 (5): 521-527


Individual variation in response and duration of anti-vascular endothelial growth factor (VEGF) therapy is seen among patients with neovascular age-related macular degeneration. Identification of genetic markers that affect clinical response may result in optimization of anti-VEGF therapy.To evaluate the pharmacogenetic relationship between genotypes of single-nucleotide polymorphisms (SNPs) in the VEGF signaling pathway and response to treatment with ranibizumab or bevacizumab for neovascular age-related macular degeneration.In total, 835 of 1149 patients (72.7%) participating in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT) at 43 CATT clinical centers.Each patient was genotyped for 7 SNPs in VEGFA (rs699946, rs699947, rs833069, rs833070, rs1413711, rs2010963, and rs2146323) and 1 SNP in VEGFR2 (rs2071559) using TaqMan SNP genotyping assays.Genotypic frequencies were compared with clinical measures of response to therapy at 1 year, including the mean visual acuity, mean change in visual acuity, at least a 15-letter increase, retinal thickness, mean change in total foveal thickness, presence of fluid on optical coherence tomography, presence of leakage on fluorescein angiography, mean change in lesion size, and mean number of injections administered. Differences in response by genotype were evaluated with tests of linear trend calculated from logistic regression models for categorical outcomes and linear regression models for continuous outcomes. The method of controlling the false discovery rate was used to adjust for multiple comparisons.For each of the measures of visual acuity evaluated, no association was observed with any of the genotypes or with the number of risk alleles. Four VEGFA SNPs demonstrated an association with retinal thickness: rs699947 (P=.03), rs833070 (P=.04), rs1413711 (P=.045), and rs2146323 (P=.006). However, adjusted P values for these associations were all statistically nonsignificant (range, P=.24 to P=.45). Among the participants in 2 as-needed groups, no association was found in the number of injections among the different genotypes or for the total number of risk alleles. The effect of risk alleles on each clinical measure did not differ by treatment group, drug, or dosing regimen (P>.01 for all).This study provides evidence that no pharmacogenetic associations exist between the studied VEGFA and VEGFR2 SNPs and response to anti-VEGF Identifier: NCT00593450.

View details for DOI 10.1001/jamaophthalmol.2014.109

View details for Web of Science ID 000337892500002

View details for PubMedID 24652518

Characterization of the Choroid-Scleral Junction and Suprachoroidal Layer in Healthy Individuals on Enhanced-Depth Imaging Optical Coherence Tomography JAMA OPHTHALMOLOGY Yiu, G., Pecen, P., Sarin, N., Chiu, S. J., Farsiu, S., Mruthyunjaya, P., Toth, C. A. 2014; 132 (2): 174-181


Accurate measurements of choroidal thickness (CT) using enhanced-depth imaging optical coherence tomography (EDI-OCT) require a well-defined choroid-scleral junction (CSJ), which may appear in some eyes as a hyporeflective band corresponding to the suprachoroidal layer (SCL).To identify factors associated with the presence and thickness of the SCL in healthy participants and determine how different CSJ boundary definitions impact CT measurements.Secondary analysis of EDI-OCT images obtained prospectively from 74 eyes of 74 controls (mean age, 68.6 years) from the Age-Related Eye Disease Study 2 Ancillary SDOCT Study.The CSJ appearances were categorized as either having no visible SCL or a hyporeflective band corresponding to the SCL. Ocular parameters associated with the presence and thickness of the SCL were identified. Subfoveal CT was measured using 3 different posterior boundaries: (1) the posterior vessel border (vascular CT [VCT]), (2) inner border of the SCL (stromal CT [StCT]), and (3) inner border of the sclera (total CT [TCT]). Manual segmentation using custom software was used to compare VCT, StCT, and TCT across the macula. RESULTS The SCL was visible in 33 eyes (44.6%). Factors associated with SCL presence and thickness included hyperopic refractive error (R2 = 0.123; P=.045) and increased TCT (R2 = 0.215; P=.004), but not age, visual acuity, intraocular pressure, retinal foveal thickness, VCT, or StCT. In eyes where the SCL was not visible, mean [SD] subfoveal VCT was 222.3 [101.5] m and StCT and TCT were 240.0 [99.0] m, with a difference of 17.7 [16.0] m (P <.001). In eyes where the SCL was visible, mean [SD] subfoveal VCT, StCT, and TCT were 221.9 [83.1] m, 257.7 [97.3] m, and 294.1 [104.8] m, respectively, with the greatest difference of 72.2 [30.4] m between VCT and TCT (P <.001). All 3 CT measurements were significantly different along all points up to 3.0 mm nasal and temporal to the fovea.A hyporeflective SCL is visible at the CSJ on EDI-OCT in nearly half of healthy individuals, and its presence correlates with hyperopia. Different posterior boundary definitions may result in significant differences in CT measurements and should be explicitly identified in future choroidal studies and segmentation algorithms.

View details for DOI 10.1001/jamaophthalmol.2013.7288

View details for Web of Science ID 000331367600009

View details for PubMedID 24336985

Reduced fluorescein angiography and fundus photography use in the management of neovascular macular degeneration and macular edema during the past decade. Investigative ophthalmology & visual science Schneider, E. W., Mruthyunjaya, P., Talwar, N., Harris Nwanyanwu, K., Nan, B., Stein, J. D. 2014; 55 (1): 542-549


We assessed recent trends in the use of diagnostic testing for neovascular age-related macular degeneration (NVAMD) and macular edema (ME).Claims data from a managed-care network were analyzed on patients with NVAMD (n = 22,954) or ME (n = 31,810) to assess the use of fluorescein angiography (FA), fundus photography (FP), and optical coherence tomography (OCT) from 2001 to 2009. Repeated-measures logistic regression was performed to compare patients' odds of undergoing these procedures in 2001, 2005, and 2009. In addition, the proportions of patients with an incident NVAMD or ME diagnosis in 2003 or 2008 who underwent FA, FP, and OCT were compared.From 2001 to 2009, among patients with NVAMD, the odds of undergoing OCT increased 23-fold, whereas the odds of receiving FA and FP decreased by 68% and 79%, respectively. Similar trends were observed for ME. From 2003 to 2008, the proportion of patients undergoing OCT within 1 year of initial diagnosis increased by 315% for NVAMD and by 143% for ME; the proportion undergoing OCT without FA within 1 year increased by 463% for NVAMD and by 216% for ME.Use of OCT increased dramatically during the past decade, whereas use of FA and FP declined considerably, suggesting that OCT may be replacing more traditional diagnostic testing in patients with NVAMD or ME. Future studies should evaluate whether this increased reliance on OCT instead of FA and FP affects patient outcomes.

View details for DOI 10.1167/iovs.13-13034

View details for PubMedID 24346174

Reduced Fluorescein Angiography and Fundus Photography Use in the Management of Neovascular Macular Degeneration and Macular Edema During the Past Decade INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Schneider, E. W., Mruthyunjaya, P., Talwar, N., Nwanyanwu, K. H., Nan, B., Stein, J. D. 2014; 55 (1): 542-549
Imaging Microscopic Pigment Chemistry in Conjunctival Melanocytic Lesions Using Pump-Probe Laser Microscopy INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Wilson, J. W., Vajzovic, L., Robles, F. E., Cummings, T. J., Mruthyunjaya, P., Warren, W. S. 2013; 54 (10): 6867-6876


To report the application of a novel imaging technique, pump-probe microscopy, to analyze patterns of pigment chemistry of conjunctival melanocytic lesion biopsies.Histopathologic specimens of eight previously excised conjunctival melanocytic lesions were analyzed with pump-probe microscopy. The technique uses a laser scanning microscope with a two-color pulsed laser source to distinguish hemoglobin, eumelanin, and pheomelanin pigment based on differences in transient excited state and ground state photodynamics. The pump-probe signatures of conjunctival melanins were compared with cutaneous melanins. The distributions of hemoglobin, eumelanin, and pheomelanin were analyzed, and pump-probe images were correlated with adjacent hematoxylin and eosin (H&E)-stained sections.The pump-probe signatures of conjunctival melanins are similar, but not identical to cutaneous melanins. In addition, there are qualitative and quantitative differences in the structure and pigment chemistry of conjunctival benign nevi, primary acquired melanosis of the conjunctiva (PAM), and conjunctival melanomas. The pump-probe images correlated well with histopathologic features observed in the adjacent H&E-stained sections, and provided a label-free means of discerning conjunctival anatomic features and pathologic benign or malignant tissue.Pump-probe laser microscopy shows promise as an adjuvant diagnostic tool in evaluation of ocular melanocytic lesions based on morphologic correlation with the histopathology results and pigment chemistry. This initial study suggests systematic differences in pigmentation patterns among conjunctival benign nevi, primary acquired melanosis, and melanomas. In addition, pump-probe microscopy has the potential for use as a noninvasive "in vivo" optical biopsy technique to aid clinical and surgical management of conjunctival melanocytic lesions.

View details for DOI 10.1167/iovs.13-12432

View details for Web of Science ID 000326567700047

View details for PubMedID 24065811

Combination therapy for macular edema secondary to retinal vein occlusion OPHTHALMIC SURGERY LASERS & IMAGING RETINA Schneider, E. W., Mruthyunjaya, P., Hariprasad, S. M. 2013; 44 (5): 434-438

View details for DOI 10.3928/23258160-20130909-02

View details for Web of Science ID 000330192400001

View details for PubMedID 24044704



The authors have recently developed a high-resolution microscope-integrated spectral domain optical coherence tomography (MIOCT) device designed to enable OCT acquisition simultaneous with surgical maneuvers. The purpose of this report is to describe translation of this device from preclinical testing into human intraoperative imaging.Before human imaging, surgical conditions were fully simulated for extensive preclinical MIOCT evaluation in a custom model eye system. Microscope-integrated spectral domain OCT images were then acquired in normal human volunteers and during vitreoretinal surgery in patients who consented to participate in a prospective institutional review board-approved study. Microscope-integrated spectral domain OCT images were obtained before and at pauses in surgical maneuvers and were compared based on predetermined diagnostic criteria to images obtained with a high-resolution spectral domain research handheld OCT system (HHOCT; Bioptigen, Inc) at the same time point. Cohorts of five consecutive patients were imaged. Successful end points were predefined, including 80% correlation in identification of pathology between MIOCT and HHOCT in 80% of the patients.Microscope-integrated spectral domain OCT was favorably evaluated by study surgeons and scrub nurses, all of whom responded that they would consider participating in human intraoperative imaging trials. The preclinical evaluation identified significant improvements that were made before MIOCT use during human surgery. The MIOCT transition into clinical human research was smooth. Microscope-integrated spectral domain OCT imaging in normal human volunteers demonstrated high resolution comparable to tabletop scanners. In the operating room, after an initial learning curve, surgeons successfully acquired human macular MIOCT images before and after surgical maneuvers. Microscope-integrated spectral domain OCT imaging confirmed preoperative diagnoses, such as full-thickness macular hole and vitreomacular traction, and demonstrated postsurgical changes in retinal morphology. Two cohorts of five patients were imaged. In the second cohort, the predefined end points were exceeded with 80% correlation between microscope-mounted OCT and HHOCT imaging in 100% of the patients.This report describes high-resolution MIOCT imaging using the prototype device in human eyes during vitreoretinal surgery, with successful achievement of predefined end points for imaging. Further refinements and investigations will be directed toward fully integrating MIOCT with vitreoretinal and other ocular surgery to image surgical maneuvers in real time.

View details for Web of Science ID 000330470700005

View details for PubMedID 23538579

Progression of Diabetic Retinopathy in the Hypertension Intervention Nurse Telemedicine Study JAMA OPHTHALMOLOGY Muir, K. W., Grubber, J., Mruthyunjaya, P., McCant, F., Bosworth, H. B. 2013; 131 (7): 957-958
Pharmacogenetics for Genes Associated with Age-related Macular Degeneration in the Comparison of AMD Treatments Trials (CATT) OPHTHALMOLOGY Hagstrom, S. A., Ying, G., Pauer, G. J., Sturgill-Short, G. M., Huang, J., Callanan, D. G., Kim, I. K., Klein, M. L., Maguire, M. G., Martin, D. F. 2013; 120 (3): 593-599


To evaluate the pharmacogenetic relationship between genotypes of single nucleotide polymorphisms (SNPs) known to be associated with age-related macular degeneration (AMD) and response to treatment with ranibizumab (Lucentis; Genentech, South San Francisco, CA) or bevacizumab (Avastin; Genentech) for neovascular AMD.Clinical trial.Eight hundred thirty-four (73%) of 1149 patients participating in the Comparison of AMD Treatments Trials (CATT) were recruited through 43 CATT clinical centers.Each patient was genotyped for SNPs rs1061170 (CFH), rs10490924 (ARMS2), rs11200638 (HTRA1), and rs2230199 (C3), using TaqMan SNP genotyping assays (Applied Biosystems, Foster City, CA).Genotypic frequencies were compared with clinical measures of response to therapy at one year, including mean visual acuity (VA), mean change in VA, 15-letter or more increase in VA, retinal thickness, mean change in total foveal thickness, presence of fluid on OCT, presence of leakage on fluorescein angiography (FA), mean change in lesion size, and mean number of injections administered. Differences in response by genotype were evaluated with tests of linear trend calculated from logistic regression models for categorical outcomes and linear regression models for continuous outcomes. To adjust for multiple comparisons, P0.01 was considered statistically significant.No statistically significant differences in response by genotype were identified for any of the clinical measures studied. Specifically, there were no high-risk alleles that predicted final VA or change in VA, the degree of anatomic response (fluid on OCT or FA, retinal thickness, change in total foveal thickness, change in lesion size), or the number of injections. Furthermore, a stepwise analysis failed to show a significant epistatic interaction among the variants analyzed; that is, response did not vary by the number of risk alleles present. The lack of association was similar whether patients were treated with ranibizumab or bevacizumab or whether they received monthly or pro re nata dosing.Although specific alleles for CFH, ARMS2, HTRA1, and C3 may predict the development of AMD, they did not predict response to anti-vascular endothelial growth factor therapy.

View details for DOI 10.1016/j.ophtha.2012.11.037

View details for Web of Science ID 000315738200025

View details for PubMedID 23337555

SD-OCT and autofluorescence characteristics of autoimmune retinopathy BRITISH JOURNAL OF OPHTHALMOLOGY Pepple, K. L., Cusick, M., Jaffe, G. J., Mruthyunjaya, P. 2013; 97 (2): 139-144


To report abnormal fundus hyperautofluorescence (hyper-AF) and loss of outer retinal layers by spectral domain optical coherence tomography in patients with autoimmune retinopathy (AIR).Retrospective, observational case series of 14 eyes of 7 patients diagnosed with an AIR for whom colour fundus photographs, fundus AF images and spectral domain optical coherence tomograms (SD-OCT) were obtained at presentation.Seven patients were identified ranging in age from 24 to 73 years. Six had a history of cancer and were diagnosed with cancer associated retinopathy or melanoma associated retinopathy. Among the seven patients, six (86%) had abnormalities by AF or SD-OCT including loss of outer retinal layers in association with hyper-AF. One patient with melanoma associated retinopathy did not have any imaging abnormalities. In one patient with cancer associated retinopathy followed over 8 months, progressive loss of retinal architecture was associated with the formation of a hyper-AF ring.Patients with AIR can present with structural abnormalities that are detectable by fundus AF and SD-OCT. The areas of hyper-AF correspond to loss of outer-retinal structures such as the inner segment/outer segment junction, the external limiting membrane and outer nuclear layer. These imaging modalities may be useful in establishing the diagnosis of this rare disease, monitoring disease progression and evaluating response to therapy.

View details for DOI 10.1136/bjophthalmol-2012-302524

View details for Web of Science ID 000313877700007

View details for PubMedID 23221966

Imaging pigment chemistry in melanocytic conjunctival lesions with pump-probe microscopy Conference on Ophthalmic Technologies XXIII as a part of the SPIE Photonics West BiOS Meeting Wilson, J. W., Vajzovic, L., Robles, F. E., Cummings, T. J., Mruthyunjaya, P., Warren, W. S. SPIE-INT SOC OPTICAL ENGINEERING. 2013

View details for DOI 10.1117/12.2003137

View details for Web of Science ID 000325430800013

Diagnostic yield of vitreous biopsy in presumed sarcoidosis-related posterior segment inflammation GRAEFES ARCHIVE FOR CLINICAL AND EXPERIMENTAL OPHTHALMOLOGY Scott, A. W., Mruthyunjaya, P., McCallum, R. M., Jaffe, G. J. 2012; 250 (9): 1379-1385


Diagnostic vitrectomy is frequently used to help establish a diagnosis in challenging uveitis cases. The usefulness of this procedure in patients with suspected sarcoidosis with posterior segment involvement, in whom a diagnosis cannot be determined by conventional methods, has not been well-described. We hypothesized that diagnostic vitrectomy would help establish a diagnosis of presumed sarcoidosis-related posterior segment inflammation in these challenging cases, and evaluated the diagnostic yield of vitreous biopsy in these eyes.Retrospective interventional case series.Diagnostic vitrectomy was performed on eyes with intermediate, posterior, or panuveitis in which an etiology could not be characterized by history, clinical examination, ancillary testing, and/or laboratory testing. Retrospective chart review was conducted on consecutive eyes that underwent diagnostic, or diagnostic and therapeutic vitrectomy by a single surgeon between January 1989 and June 2006.Diagnostic and therapeutic vitrectomy was performed on 150 eyes. The final diagnosis was established by positive vitreous fluid analysis in 63 eyes (42 %). Eight of these vitreous specimens (5.3 %) yielded cytopathology consistent with presumed sarcoidosis-related posterior segment inflammation.Sarcoidosis can cause characteristic inflammatory changes in the vitreous. In the appropriate clinical setting, cytopathologic assessment of these inflammatory changes observed in vitreous specimens can support the diagnosis of presumed sarcoidosis-related posterior segment inflammation, and help direct clinical management.

View details for DOI 10.1007/s00417-012-1993-9

View details for Web of Science ID 000307993900018

View details for PubMedID 22434211

Collaborative Ocular Oncology Group Report Number 1: Prospective Validation of a Multi-Gene Prognostic Assay in Uveal Melanoma OPHTHALMOLOGY Onken, M. D., Worley, L. A., Char, D. H., Augsburger, J. J., Correa, Z. M., Nudleman, E., Aaberg, T. M., Altaweel, M. M., Bardenstein, D. S., Finger, P. T., Gallie, B. L., Harocopos, G. J., Hovland, P. G., McGowan, H. D., Milman, T., Mruthyunjaya, P., Simpson, E. R., Smith, M. E., Wilson, D. J., Wirostko, W. J., Harbour, J. W. 2012; 119 (8): 1596-1603


This study evaluates the prognostic performance of a 15 gene expression profiling (GEP) assay that assigns primary posterior uveal melanomas to prognostic subgroups: class 1 (low metastatic risk) and class 2 (high metastatic risk).Prospective, multicenter study.A total of 459 patients with posterior uveal melanoma were enrolled from 12 independent centers.Tumors were classified by GEP as class 1 or class 2. The first 260 samples were also analyzed for chromosome 3 status using a single nucleotide polymorphism assay. Net reclassification improvement analysis was performed to compare the prognostic accuracy of GEP with the 7th edition clinical Tumor-Node-Metastasis (TNM) classification and chromosome 3 status.Patients were managed for their primary tumor and monitored for metastasis.The GEP assay successfully classified 446 of 459 cases (97.2%). The GEP was class 1 in 276 cases (61.9%) and class 2 in 170 cases (38.1%). Median follow-up was 17.4 months (mean, 18.0 months). Metastasis was detected in 3 class 1 cases (1.1%) and 44 class 2 cases (25.9%) (log-rank test, P<10(-14)). Although there was an association between GEP class 2 and monosomy 3 (Fisher exact test, P<0.0001), 54 of 260 tumors (20.8%) were discordant for GEP and chromosome 3 status, among which GEP demonstrated superior prognostic accuracy (log-rank test, P = 0.0001). By using multivariate Cox modeling, GEP class had a stronger independent association with metastasis than any other prognostic factor (P<0.0001). Chromosome 3 status did not contribute additional prognostic information that was independent of GEP (P = 0.2). At 3 years follow-up, the net reclassification improvement of GEP over TNM classification was 0.43 (P = 0.001) and 0.38 (P = 0.004) over chromosome 3 status.The GEP assay had a high technical success rate and was the most accurate prognostic marker among all of the factors analyzed. The GEP provided a highly significant improvement in prognostic accuracy over clinical TNM classification and chromosome 3 status. Chromosome 3 status did not provide prognostic information that was independent of GEP.

View details for DOI 10.1016/j.ophtha.2012.02.017

View details for Web of Science ID 000307080100016

View details for PubMedID 22521086

Association of Vitamin D Deficiency and Age-Related Macular Degeneration in Medicare Beneficiaries ARCHIVES OF OPHTHALMOLOGY Day, S., Acquah, K., Platt, A., Lee, P. P., Mruthyunjaya, P., Sloan, F. A. 2012; 130 (8): 1070-1071

View details for Web of Science ID 000307455800022

View details for PubMedID 22893083

Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two-year results. Ophthalmology Martin, D. F., Maguire, M. G., Fine, S. L., Ying, G., Jaffe, G. J., Grunwald, J. E., Toth, C., Redford, M., Ferris, F. L. 2012; 119 (7): 1388-1398


To describe effects of ranibizumab and bevacizumab when administered monthly or as needed for 2 years and to describe the impact of switching to as-needed treatment after 1 year of monthly treatment.Multicenter, randomized clinical trial.Patients (n = 1107) who were followed up during year 2 among 1185 patients with neovascular age-related macular degeneration who were enrolled in the clinical trial.At enrollment, patients were assigned to 4 treatment groups defined by drug (ranibizumab or bevacizumab) and dosing regimen (monthly or as needed). At 1 year, patients initially assigned to monthly treatment were reassigned randomly to monthly or as-needed treatment, without changing the drug assignment.Mean change in visual acuity.Among patients following the same regimen for 2 years, mean gain in visual acuity was similar for both drugs (bevacizumab-ranibizumab difference, -1.4 letters; 95% confidence interval [CI], -3.7 to 0.8; P = 0.21). Mean gain was greater for monthly than for as-needed treatment (difference, -2.4 letters; 95% CI, -4.8 to -0.1; P = 0.046). The proportion without fluid ranged from 13.9% in the bevacizumab-as-needed group to 45.5% in the ranibizumab monthly group (drug, P = 0.0003; regimen, P < 0.0001). Switching from monthly to as-needed treatment resulted in greater mean decrease in vision during year 2 (-2.2 letters; P = 0.03) and a lower proportion without fluid (-19%; P < 0.0001). Rates of death and arteriothrombotic events were similar for both drugs (P > 0.60). The proportion of patients with 1 or more systemic serious adverse events was higher with bevacizumab than ranibizumab (39.9% vs. 31.7%; adjusted risk ratio, 1.30; 95% CI, 1.07-1.57; P = 0.009). Most of the excess events have not been associated previously with systemic therapy targeting vascular endothelial growth factor (VEGF).Ranibizumab and bevacizumab had similar effects on visual acuity over a 2-year period. Treatment as needed resulted in less gain in visual acuity, whether instituted at enrollment or after 1 year of monthly treatment. There were no differences between drugs in rates of death or arteriothrombotic events. The interpretation of the persistence of higher rates of serious adverse events with bevacizumab is uncertain because of the lack of specificity to conditions associated with inhibition of VEGF.

View details for DOI 10.1016/j.ophtha.2012.03.053

View details for PubMedID 22555112

Image Inversion Spectral-Domain Optical Coherence Tomography Optimizes Choroidal Thickness and Detail through Improved Contrast INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Lin, P., Mettu, P. S., Pomerleau, D. L., Chiu, S. J., Maldonado, R., Stinnett, S., Toth, C. A., Farsiu, S., Mruthyunjaya, P. 2012; 53 (4): 1874-1882


This study was conducted to determine whether there were significant differences in choroidal thickness, contrast, outer choroidal vessel (OCV), and choroidal-scleral junction (CSJ) visualization in inverted versus upright spectral-domain optical coherence tomography (SD-OCT).Images were captured on Bioptigen SD-OCT, Zeiss Cirrus HD-OCT, and Heidelberg Spectralis in 42 eyes of 21 healthy subjects. Average choroidal thickness across a fovea-centered 4-mm segment was determined with MATLAB. Quantitative measures of choroidal contrast were measured and CSJ assessed by applying a score of 0 to 3. OCV was determined by counting choroidal vessels 200 m.Mean choroidal thickness was greater in inverted versus upright images captured by Bioptigen (P 0.003) and Spectralis (P 0.015). Choroidal thickness varied significantly between the three machines (P < 0.05). Contrast was higher in inverted versus upright images captured by Bioptigen (P 0.02) and Spectralis (P < 0.001), but not in Cirrus (P > 0.10, both observers). CSJ score was highest in the following: Spectralis inverted = Spectralis EDI > Cirrus upright > Bioptigen inverted. Mean OCV was highest in Spectralis inverted mode.The most favorable modes to visualize CSJ and OCV are the Spectralis EDI, Spectralis inverted, Cirrus upright, and Bioptigen inverted. These modes demonstrate the highest outer choroidal contrast and choroidal thickness measurements. Choroidal thickness cannot be compared between machines due to conversion factor differences. Future studies and construction of automated segmentation and detection software should take these benefits and pitfalls into account.

View details for DOI 10.1167/iovs.11-9290

View details for Web of Science ID 000303669400023

View details for PubMedID 22410550

Unanticipated Vision Loss After Pars Plana Vitrectomy SURVEY OF OPHTHALMOLOGY Jain, N., McCuen, B. W., Mruthyunjaya, P. 2012; 57 (2): 91-104


Although advances in vitreoretinal surgical techniques and technology have helped to minimize the risks associated with surgical manipulation of the retina, retinal pigment epithelium, and optic nerve, unanticipated or unexplained visual loss still occurs. We review causes of vision loss encountered after pars plana vitrectomy, including retinal toxicities, vascular events, and optic neuropathies, and we suggest strategies to limit or prevent them.

View details for DOI 10.1016/j.survophthal.2011.09.001

View details for Web of Science ID 000301034500001

View details for PubMedID 22337337

Retinal manifestations of oncologic and hematologic conditions. International ophthalmology clinics Lin, P., Mruthyunjaya, P. 2012; 52 (1): 67-91

View details for DOI 10.1097/IIO.0b013e31823bbd14

View details for PubMedID 22124239

Medicare Costs for Neovascular Age-Related Macular Degeneration, 1994-2007 AMERICAN JOURNAL OF OPHTHALMOLOGY Day, S., Acquah, K., Lee, P. P., Mruthyunjaya, P., Sloan, F. A. 2011; 152 (6): 1014-1020


To assess changes in Medicare payments for neovascular age-related macular degeneration (AMD) since introduction of anti-vascular endothelial growth factor (VEGF) therapies.Retrospective, longitudinal cohort study.Using the Medicare 5% sample, beneficiaries with new diagnoses of neovascular AMD in 1994 (N = 2497), 2000 (N = 3927), and 2006 (N = 6041) were identified using International Classification of Diseases (ICD-9-CM). The total first-year health care and eye care costs were calculated for each beneficiary. Propensity score matching was used to match individuals in the 2000 and 2006 cohorts with the 1994 cohort on age, sex, race, Charlson Comorbidity Index, and low vision/blindness.The number of beneficiaries newly diagnosed with neovascular AMD more than doubled between the 1994 and 2006 cohorts. Overall yearly Part B payments per beneficiary increased significantly from $3567 for the 1994 to $5991 for the 2006 cohort (P < .01) in constant 2008 dollars. Payments for eye care alone doubled from $1504 for the 1994 cohort to $3263 for the 2006 cohort (P < .01). Most of the increase in payments for eye care in 2006 reflected payments for anti-VEGF injections, which were $1609 over 1 year. Mean annual numbers of visits and imaging studies also increased significantly between the 1994 and 2006 cohort. Results were similar in the matched sample.The introduction of anti-VEGF intravitreal injections has offered remarkable clinical benefits for patients with neovascular AMD, but these benefits have come at the cost of an increased financial burden of providing care for these patients.

View details for DOI 10.1016/j.ajo.2011.05.008

View details for Web of Science ID 000297714900016

View details for PubMedID 21843875

Ocular Complications After Anti-Vascular Endothelial Growth Factor Therapy in Medicare Patients With Age-Related Macular Degeneration AMERICAN JOURNAL OF OPHTHALMOLOGY Day, S., Acquah, K., Mruthyunjaya, P., Grossman, D. S., Lee, P. P., Sloan, F. A. 2011; 152 (2): 266-272


To determine longitudinal rates of ocular complications after anti-vascular endothelial growth factor (VEGF) treatment for neovascular age-related macular degeneration (AMD) in a nationally representative longitudinal sample.Retrospective, longitudinal case-control study.Using the Medicare 5% claims database, diagnoses of neovascular AMD and anti-VEGF injections of ranibizumab, bevacizumab, or pegaptanib were identified from International Classification of Diseases and Current Procedural Terminology procedure codes. Six thousand one hundred fifty-four individuals undergoing anti-VEGF treatment for neovascular AMD (total of 40 903 injections) were compared with 6154 matched controls with neovascular AMD who did not undergo anti-VEGF treatment. Propensity score matching was used to match individuals receiving anti-VEGF injections with controls. Rates of postinjection adverse outcomes (endophthalmitis, rhegmatogenous retinal detachment, retinal tear, uveitis, and vitreous hemorrhage) were analyzed by cumulative incidence and Cox proportional hazards model to control for demographic factors and ocular comorbidities.At the 2-year follow-up, the rates of endophthalmitis per injection (0.09%; P<.01), uveitis (0.11%; P<.01), and vitreous hemorrhage per injection (0.23%; P < .01) were significantly higher in the anti-VEGF treatment group. With Cox proportional hazards modeling, the anti-VEGF treatment group had a 102% higher risk of severe ocular complications overall and a 4% increased risk per injection, both of which were statistically significant (P<.01).Rates of endophthalmitis, uveitis, and vitreous hemorrhage were higher in the group treated with anti-VEGF injection than in the control group, although these nevertheless were rare in both groups. The overall risk of severe ocular complications was significantly higher in the anti-VEGF treatment group.

View details for DOI 10.1016/j.ajo.2011.01.053

View details for Web of Science ID 000293317900018

View details for PubMedID 21664593

Melanoma-associated retinopathy: a presenting sign of metastatic disease. Journal of the American Academy of Dermatology Handler, M. Z., Mruthyunjaya, P., Nelson, K. 2011; 65 (1): e9-11

View details for DOI 10.1016/j.jaad.2010.09.015

View details for PubMedID 21679809

Optimizing Diagnosis and Management of Nocardia Keratitis, Scleritis, and Endophthalmitis: 11-Year Microbial and Clinical Overview OPHTHALMOLOGY DeCroos, F. C., Garg, P., Reddy, A. K., Sharma, A., Krishnaiah, S., Mungale, M., Mruthyunjaya, P. 2011; 118 (6): 1193-1200


To identify clinical factors and microbiological assays that facilitate a rapid diagnosis of Nocardia keratitis, scleritis, and endophthalmitis, and to determine optimal medical and surgical management strategies.Retrospective, consecutive case series.A total of 111 cases of keratitis, 11 cases of scleritis, and 16 cases of endophthalmitis, all culture-proven Nocardia infections, were identified between January 1999 and January 2010.The keratitis cases underwent intensive medical management, and the scleritis and endophthalmitis cases required concurrent surgical intervention for disease control. Corneal and scleral scrapings, as well as undiluted vitreous sample, were submitted for microbiologic evaluation (direct smear and culture).Historical points, clinical findings, and microbiologic assays that facilitated a prompt Nocardia diagnosis were identified, and management choices were examined for correlation with final acuity.Ocular exposure to soil or plant matter was a common historical point in cases of Nocardia keratitis (48%) and scleritis (45%), respectively. Nocardia keratitis often (38.7%) presented with "wreath"-shaped anterior stromal infiltrate or infiltrate interspersed with elevated, pinhead-sized, chalky lesions. Most patients with scleritis (63.4%) presented with nodular lesions demonstrating pointed abscesses. Nocardia endophthalmitis typically (75%) presented with endoexudates or nodular exudates surrounding the pupillary border. Gram stain and 1% acid-fast stain enabled prompt diagnosis of Nocardia in 64% and 63% of keratitis cases and 45% and 63% of scleritis cases, respectively. Direct smear was usually not revealing in cases of Nocardia endophthalmitis. Isolates from Nocardia keratitis, scleritis, and endophthalmitis demonstrated 97%, 100%, and 90% susceptibility to amikacin, respectively. Nocardia keratitis resolved with medical therapy alone in 82% of cases. Younger age and better initial acuity correlated with improved final acuity in keratitis cases. Outcomes were poor after Nocardia scleritis and endophthalmitis.Early appropriate treatment often results in visual recovery in eyes with Nocardia keratitis. Despite aggressive and prompt surgical intervention, the prognosis for Nocardia scleritis and endophthalmitis is more guarded. Nocardia isolated from ocular infections demonstrate high levels of susceptibility to amikacin.The author(s) have no proprietary or commercial interest in any materials discussed in this article.

View details for DOI 10.1016/j.ophtha.2010.10.037

View details for Web of Science ID 000291152700029

View details for PubMedID 21276615

Ranibizumab and bevacizumab for neovascular age-related macular degeneration. New England journal of medicine Martin, D. F., Maguire, M. G., Ying, G., Grunwald, J. E., Fine, S. L., Jaffe, G. J. 2011; 364 (20): 1897-1908


Clinical trials have established the efficacy of ranibizumab for the treatment of neovascular age-related macular degeneration (AMD). In addition, bevacizumab is used off-label to treat AMD, despite the absence of similar supporting data.In a multicenter, single-blind, noninferiority trial, we randomly assigned 1208 patients with neovascular AMD to receive intravitreal injections of ranibizumab or bevacizumab on either a monthly schedule or as needed with monthly evaluation. The primary outcome was the mean change in visual acuity at 1 year, with a noninferiority limit of 5 letters on the eye chart.Bevacizumab administered monthly was equivalent to ranibizumab administered monthly, with 8.0 and 8.5 letters gained, respectively. Bevacizumab administered as needed was equivalent to ranibizumab as needed, with 5.9 and 6.8 letters gained, respectively. Ranibizumab as needed was equivalent to monthly ranibizumab, although the comparison between bevacizumab as needed and monthly bevacizumab was inconclusive. The mean decrease in central retinal thickness was greater in the ranibizumab-monthly group (196 m) than in the other groups (152 to 168 m, P=0.03 by analysis of variance). Rates of death, myocardial infarction, and stroke were similar for patients receiving either bevacizumab or ranibizumab (P>0.20). The proportion of patients with serious systemic adverse events (primarily hospitalizations) was higher with bevacizumab than with ranibizumab (24.1% vs. 19.0%; risk ratio, 1.29; 95% confidence interval, 1.01 to 1.66), with excess events broadly distributed in disease categories not identified in previous studies as areas of concern.At 1 year, bevacizumab and ranibizumab had equivalent effects on visual acuity when administered according to the same schedule. Ranibizumab given as needed with monthly evaluation had effects on vision that were equivalent to those of ranibizumab administered monthly. Differences in rates of serious adverse events require further study. (Funded by the National Eye Institute; number, NCT00593450.).

View details for DOI 10.1056/NEJMoa1102673

View details for PubMedID 21526923

Retinal Pigment Epithelial Detachments in Age-Related Macular Degeneration: Classification and Therapeutic Options SEMINARS IN OPHTHALMOLOGY Pepple, K., Mruthyunjaya, P. 2011; 26 (3): 198-208


Retinal pigment epithelial detachment (PED) is an important predictor of vision loss in patients with age-related macular degeneration (AMD). Here we review the historical PEDs subtypes, include recent insights into PED pathogenesis provided by modern imaging modalities, and summarize the current options for treatment.

View details for DOI 10.3109/08820538.2011.570850

View details for Web of Science ID 000293502200016

View details for PubMedID 21609233

Bacterial Contamination of Needles Used for Intravitreal Injections:A Prospective, Multicenter Study OCULAR IMMUNOLOGY AND INFLAMMATION Stewart, J. M., Srivastava, S. K., Fung, A. E., Mahmoud, T. H., Telander, D. G., Hariprasad, S. M., Ober, M. D., Mruthyunjaya, P. 2011; 19 (1): 32-38


To determine the incidence of bacterial contamination of needles used for intravitreal injections.Patients undergoing intravitreal injections were enrolled prospectively. No pre-injection antibiotics were administered. Following povidone-iodine irrigation, conjunctival cultures were taken and the injection was performed. The needle was cultured. A dry control needle was exposed to the surgical field and cultured.No patients developed endophthalmitis. Eighteen injection needles (18%) yielded positive bacterial growth. The most commonly encountered organisms were Propionibacterium acnes (n=8) and Staphylococcus epidermidis (n=6). Four control needles showed positive growth, in 2 cases with the same organism as a matching positive used needle. The difference between contamination rates of used and control needles was significant (p=.002, McNemar's test).Bacterial contaminants are present on a substantial proportion of needles. Since the needle contacts both the ocular surface and the vitreous, it is possible that inoculation of the vitreous cavity occurs in such cases.

View details for DOI 10.3109/09273948.2010.520405

View details for Web of Science ID 000288355300006

View details for PubMedID 21034310

Evaluation of Contrast Agents for Enhanced Visualization in Optical Coherence Tomography INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE Ehlers, J. P., Gupta, P. K., Farsiu, S., Maldonado, R., Kim, T., Toth, C. A., Mruthyunjaya, P. 2010; 51 (12): 6614-6619


To identify and evaluate the use of contrast agents in optical coherence tomography (OCT) for ophthalmic applications.Three agents-prednisolone acetate (PA), triamcinolone acetonide (TA), and lipid-based artificial tears (LBAT)-were tested in cadaveric porcine eyes imaged with hand-held spectral-domain OCT (SD-OCT). Anterior segment imaging was performed in triplicate with each agent at three sites: corneal epithelial surface, corneal wound interface, and anterior chamber. OCT characteristics of the three agents at each ocular site were analyzed. Quantitative intensity (i.e., brightness) analysis was performed with image analysis software. Institutional review board approval was obtained for imaging in human subjects undergoing cataract surgery. PA was applied to the corneal surface, and SD-OCT imaging was performed of the corneal surface and wound interface immediately after cataract surgery.All agents provided increased reflectivity. PA and LBAT showed a smooth bright reflectivity profile, whereas TA had a granular profile. Improved visualization of tissue interfaces was noted. Maximum and mean intensity of reflectance were higher for all agents compared with controls (P < 0.05). PA showed topical and wound interface contrast enhancement in human subjects after cataract surgery.Significant OCT contrast enhancement was achieved with improved visualization of tissue interfaces. Each agent had a unique reflectivity profile. Future applications of OCT contrast agents might include evaluation of wound stability, intraocular fluidics, and ocular surface disease.

View details for DOI 10.1167/iovs.10-6195

View details for Web of Science ID 000284837500068

View details for PubMedID 21051711

One-Year Outcomes After Retinal Detachment Surgery Among Medicare Beneficiaries AMERICAN JOURNAL OF OPHTHALMOLOGY Day, S., Grossman, D. S., Mruthyunjaya, P., Sloan, F. A., Lee, P. P. 2010; 150 (3): 338-345


To determine longitudinal rates of second retinal detachment operation and postoperative adverse outcomes after retinal detachment surgery in a nationally representative sample of older Americans.Retrospective, longitudinal cohort analysis.A total of 9216 Medicare beneficiaries were identified from the Medicare 5% sample who were diagnosed with rhegmatogenous retinal detachment and underwent primary pars plana vitrectomy (PPV), scleral buckle, pneumatic retinopexy, or laser photocoagulation or cryotherapy alone. Rhegmatogenous retinal detachment, PPV, scleral buckle, pneumatic retinopexy, or laser photocoagulation/cryotherapy was ascertained from International Classification of Diseases and Current Procedural Terminology procedure codes. Rates of second retinal detachment operation and postoperative adverse outcomes were analyzed by cumulative incidence and logistic regression to control for prior adverse outcome measures and demographic factors.At 1-year follow-up, the rate of receipt of a second retinal detachment operation for beneficiaries who had undergone primary pneumatic retinopexy was much higher (40.6%, P < .0001) relative to the scleral buckle (19.2%) group. After controlling for demographic variables and ocular comorbidities, pneumatic retinopexy individuals were nearly 3 times more likely to receive a second retinal detachment surgery than scleral buckle individuals. No significant differences exist in risk of second retinal detachment surgery for the PPV compared to the scleral buckle group. Individuals receiving PPV were 2 times more likely to suffer adverse outcomes than were those undergoing scleral buckle. Results were robust in sensitivity analysis.Rates of second operation were much higher after pneumatic retinopexy than PPV or scleral buckle, and rates of adverse outcomes were higher in PPV, even after controlling for risk factors and demographic variables.

View details for DOI 10.1016/j.ajo.2010.04.009

View details for Web of Science ID 000281781800007

View details for PubMedID 20591398

Postoperative cilioretinal artery occlusion in Sturge Weber-associated glaucoma JOURNAL OF AAPOS Chang, L., Mruthyunjaya, P., Rodriguez-Rosa, R. E., Freedman, S. F. 2010; 14 (4): 358-360


Surgical management of Sturge Weber-associated glaucoma is challenging. Choroidal effusion and expulsive choroidal hemorrhage are commonly cited potential risks. We report a case of a cilioretinal artery occlusion associated with glaucoma drainage device surgery in a child with refractory Sturge Weber-associated glaucoma.

View details for DOI 10.1016/j.jaapos.2010.04.014

View details for Web of Science ID 000281524600014

View details for PubMedID 20621528

Transpositional Autokeratoplasty in a Patient with Unilateral Choroidal Melanoma and Contralateral Exposure Keratopathy. Ophthalmic surgery, lasers & imaging : the official journal of the International Society for Imaging in the Eye Mehta, H., Hungerford, J. L., Gartry, D. S., Herbert, H. M., Mruthyunjaya, P. 2010: 1-3


Penetrating keratoplasty was required to improve corneal clarity in the left eye, which had suffered chronic exposure keratopathy following a cerebellopontine angle tumor with facial nerve involvement. The right eye had a large choroidal melanoma, which had failed brachytherapy, but the cornea was transparent and healthy. The right eye corneal button was sutured to the left eye host and a donor corneal button was sutured to the right eye rim. The right eye was subsequently enucleated. Two years later, the patient had 6/12 visual acuity with a clear graft and no tumor seeding in the host eye. Although limited opportunities arise to employ transpositional autokeratoplasty, where appropriate, it offers an alternative to conventional allokeratoplasty with a lower risk of immune rejection.

View details for DOI 10.3928/15428877-20100215-41

View details for PubMedID 20337330

SCORE Study Report 7: Incidence of Intravitreal Silicone Oil Droplets Associated With Staked-on vs Luer Cone Syringe Design AMERICAN JOURNAL OF OPHTHALMOLOGY Scott, I. U., Oden, N. L., VanVeldhuisen, P. C., Ip, M. S., Blodi, B. A., Antoszyk, A. N. 2009; 148 (5): 725-732


To evaluate the incidence of intravitreal silicone oil (SO) droplets associated with intravitreal injections using a staked-on vs luer cone syringe design in the SCORE (Standard Care vs COrticosteroid in REtinal Vein Occlusion) Study.Prospective, randomized, phase III clinical trial.The incidence of intravitreal SO was compared among participants exposed to the staked-on syringe design, the luer cone syringe design, or both of the syringe designs in the SCORE Study, which evaluated intravitreal triamcinolone acetonide injection(s) for vision loss secondary to macular edema associated with central or branch retinal vein occlusion. Injections were given at baseline and 4-month intervals, based on treatment assignment and study-defined retreatment criteria. Because intravitreal SO was observed following injections in some participants, investigators were instructed, on September 22, 2006, to look for intravitreal SO at all study visits. On November 1, 2007, the luer cone syringe design replaced the staked-on syringe design.A total of 464 participants received a total of 1,205 injections between November 4, 2004 and February 28, 2009. Intravitreal SO was noted in 141 of 319 participants (44%) exposed only to staked-on syringes, 11 of 87 (13%) exposed to both syringe designs, and 0 of 58 exposed only to luer cone syringes (P < .0001). Among participants with first injections after September 22, 2006, intravitreal SO was noted in 65 of 114 (57%) injected only with staked-on syringes compared with 0 of 58 injected only with luer cone syringes. Differential follow-up is unlikely to explain these results.In the SCORE Study, luer cone syringe design is associated with a lower frequency of intravitreal SO droplet occurrence compared with the staked-on syringe design, likely attributable to increased residual space in the needle hub with the luer cone design.

View details for DOI 10.1016/j.ajo.2009.06.004

View details for Web of Science ID 000271669300014

View details for PubMedID 19674727

A Randomized Trial Comparing the Efficacy and Safety of Intravitreal Triamcinolone With Standard Care to Treat Vision Loss Associated With Macular Edema Secondary to Branch Retinal Vein Occlusion The Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) Study Report 6 ARCHIVES OF OPHTHALMOLOGY Scott, I. U., Ip, M. S., VanVeldhuisen, P. C., Oden, N. L., Blodi, B. A., Fisher, M., Chan, C. K., Gonzalez, V. H., Singerman, L. J., Tolentino, M. 2009; 127 (9): 1115-1128


To compare the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone with standard care (grid photocoagulation in eyes without dense macular hemorrhage and deferral of photocoagulation until hemorrhage clears in eyes with dense macular hemorrhage) for eyes with vision loss associated with macular edema secondary to branch retinal vein occlusion (BRVO).Multicenter, randomized clinical trial of 411 participants. Main Outcome Measure Gain in visual acuity letter score of 15 or more from baseline to month 12.Twenty-nine percent, 26%, and 27% of participants achieved the primary outcome in the standard care, 1-mg, and 4-mg groups, respectively. None of the pairwise comparisons between the 3 groups was statistically significant at month 12. The rates of elevated intraocular pressure and cataract were similar for the standard care and 1-mg groups, but higher in the 4-mg group.There was no difference identified in visual acuity at 12 months for the standard care group compared with the triamcinolone groups; however, rates of adverse events (particularly elevated intraocular pressure and cataract) were highest in the 4-mg group. Application to Clinical Practice Grid photocoagulation as applied in the SCORE Study remains the standard care for patients with vision loss associated with macular edema secondary to BRVO who have characteristics similar to participants in the SCORE-BRVO trial. Grid photocoagulation should remain the benchmark against which other treatments are compared in clinical trials for eyes with vision loss associated with macular edema secondary to BRVO. Trial Registration Identifier: NCT00105027.

View details for Web of Science ID 000269765500002

View details for PubMedID 19752420

A Randomized Trial Comparing the Efficacy and Safety of Intravitreal Triamcinolone With Observation to Treat Vision Loss Associated With Macular Edema Secondary to Central Retinal Vein Occlusion The Standard Care vs Corticosteroid for Retinal Vein Occlusion (SCORE) Study Report 5 ARCHIVES OF OPHTHALMOLOGY Ip, M. S., Scott, I. U., VanVeldhuisen, P. C., Oden, N. L., Blodi, B. A., Fisher, M., Singerman, L. J., Tolentino, M., Chan, C. K., Gonzalez, V. H. 2009; 127 (9): 1101-1114


To compare the efficacy and safety of 1-mg and 4-mg doses of preservative-free intravitreal triamcinolone with observation for eyes with vision loss associated with macular edema secondary to perfused central retinal vein occlusion (CRVO).Multicenter, randomized, clinical trial of 271 participants.Gain in visual acuity letter score of 15 or more from baseline to month 12.Seven percent, 27%, and 26% of participants achieved the primary outcome in the observation, 1-mg, and 4-mg groups, respectively. The odds of achieving the primary outcome were 5.0 times greater in the 1-mg group than the observation group (odds ratio [OR], 5.0; 95% confidence interval [CI], 1.8-14.1; P = .001) and 5.0 times greater in 4-mg group than the observation group (OR, 5.0; 95% CI, 1.8-14.4; P = .001); there was no difference identified between the 1-mg and 4-mg groups (OR, 1.0; 95% CI, 0.5-2.1; P = .97). The rates of elevated intraocular pressure and cataract were similar for the observation and 1-mg groups, but higher in the 4-mg group.Intravitreal triamcinolone is superior to observation for treating vision loss associated with macular edema secondary to CRVO in patients who have characteristics similar to those in the SCORE-CRVO trial. The 1-mg dose has a safety profile superior to that of the 4-mg dose. Application to Clinical Practice Intravitreal triamcinolone in a 1-mg dose, following the retreatment criteria applied in the SCORE Study, should be considered for up to 1 year, and possibly 2 years, for patients with characteristics similar to those in the SCORE-CRVO trial. Trial Registration Identifier: NCT00105027.

View details for Web of Science ID 000269765500001

View details for PubMedID 19752419

Unusual case of diffuse choroidal melanoma masquerading as atypical central serous chorioretinopathy. Retinal cases & brief reports Scott, A. W., Fekrat, S., Mruthyunjaya, P., Cummings, T. J., Cooney, M. J. 2008; 2 (4): 280-285


To describe an unusual case of diffuse circumpapillary choroidal melanoma masquerading as atypical central serous chorioretinopathy, and to describe fluorescein angiographic and optical coherence tomography characteristics of this diffuse choroidal melanoma.Interventional case report.A 46-year-old human immunodeficiency virus-positive man presented with an 11-month history of decreased vision and the absence of an elevated choroidal lesion. The patient failed to return for follow-up.Thirteen months after his initial presentation, circumpapillary diffuse choroidal melanoma was diagnosed. The patient underwent enucleation. No extrascleral extension was present.Imaging characteristics on fluorescein angiography or optical coherence tomography may be of diagnostic value to aid the ophthalmologist in earlier detection of diffuse choroidal melanomas.

View details for DOI 10.1097/ICB.0b013e318156d799

View details for PubMedID 25390591

Identification of patients with diabetic macular edema from claims data - A validation study ARCHIVES OF OPHTHALMOLOGY Bearelly, S., Mruthyunjaya, P., Tzeng, J. P., Suner, I. J., Shea, A. M., Lee, J. T., Kowalski, J. W., Curtis, L. H., Schulman, K. A., Lee, P. P. 2008; 126 (7): 986-989


To assess the validity of an algorithm for identifying patients with diabetic macular edema (DME) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes in administrative billing data from a convenience sample of physician offices.A convenience sample of 12 general ophthalmologists and 10 retina specialists applied prespecified algorithms based on ICD-9-CM diagnosis codes to the billing claims of their practices and selected the associated medical records. Four ophthalmologists abstracted data from the medical records, which were then compared with the coded diagnoses. Main outcome measures were sensitivity, specificity, and the kappa statistic for the DME algorithm (a combination of codes 250.xx and 362.53), treating medical record documentation of DME as the standard criterion.The DME algorithm had a sensitivity of 0.88 and a specificity of 0.96 for identifying DME. Excellent agreement was noted between the algorithm and the medical records (kappa = 0.84). The algorithm performed less well in identifying patients with a diagnosis of clinically significant DME (sensitivity, 0.86; specificity, 0.84; kappa = 0.64).The results of this pilot study suggest that patients with DME can be identified accurately in claims data using ICD-9-CM diagnosis codes. Application of this algorithm could improve investigations of disease prevalence and disease burden and provide an efficient means of assessing care and interventions.

View details for Web of Science ID 000257511300016

View details for PubMedID 18625948

Choroidal Metastasis of Follicular Thyroid Adenocarcinoma Diagnosed by 25-Gauge Transretinal Biopsy ANNALS OF OPHTHALMOLOGY Scott, A. W., Cummings, T. J., Kirkpatrick, J. P., Mruthyunjaya, P. 2008; 40 (2): 110-112


We report a case of a patient with previously treated follicular thyroid carcinoma who presented with a symptomatic amelanotic choroidal mass with low internal reflectivity and a metastatic lytic skull lesion. A 25-gauge vitrector was used to perform transretinal choroidal biopsy (TRCB), confirming the diagnosis of metastatic follicular thyroid carcinoma.

View details for Web of Science ID 000260909700011

View details for PubMedID 19013920

Malignant transformation of iris melanocytoma to iris ring melanoma BRITISH JOURNAL OF OPHTHALMOLOGY Sagoo, M. S., Mruthyunjaya, P., Cree, I., Luthert, P. J., Hungerford, J. L. 2007; 91 (11): 1571-1572

View details for DOI 10.1136/bjo.2006.105858

View details for Web of Science ID 000250229300047

View details for PubMedID 17947283

Efficacy of low-release-rate fluocinolone acetonide intravitreal implants to treat experimental uveitis ARCHIVES OF OPHTHALMOLOGY Mruthyunjaya, P., Khalatbari, D., Yang, P., Stinnett, S., Tano, R., Ashton, P., Guo, H., Nazzaro, M., Jaffe, G. J. 2006; 124 (7): 1012-1018


To determine the efficacy of 0.5-mg and 0.1-mg sustained-release fluocinolone acetonide intravitreal implants to inhibit ocular inflammation in a rabbit model of severe uveitis.The in vitro pharmacokinetic profile of both the 0.5-mg and 0.1-mg sustained-release fluocinolone intravitreal implants was determined during a 10-day period. A sustained-release fluocinolone acetonide intravitreal implant with a release rate of either 0.5 microg/d (n = 16) or 0.1 microg/d (n = 16) was implanted into the vitreous cavity of the right eye in albino rabbits after a subcutaneous injection of tuberculin antigen. Control animals (n = 14) received empty devices. Uveitis was induced with an intravitreal tuberculin antigen injection. A masked observer graded anterior chamber flare, anterior chamber cells, vitreous opacity, and inflammation on histologic sections.In vitro, the drug was released from both devices in a linear manner. In vivo, treated eyes were significantly less inflamed than untreated eyes (P< or =.02). Inflammation was suppressed to a greater degree with the 0.5-microg/d implant compared with the 0.1-microg/d implant.Sustained-release fluocinolone intravitreal implants suppress ocular inflammation in a rabbit model of severe uveitis.The efficacy demonstrated with the 0.1-microg/d implant provides the rationale for future human studies with lower-release-rate implants than are currently used in noninfectious uveitis clinical trials.

View details for Web of Science ID 000239123200010

View details for PubMedID 16832025

Central retinal vein occlusion in patients treated with long-term warfarin sodium (Coumadin) for anticoagulation RETINA-THE JOURNAL OF RETINAL AND VITREOUS DISEASES Mruthyunjaya, P., Wirostko, W. J., Chandrashekhar, R., Stinnett, S., Lai, J. C., Deramo, V., Tang, J., Dev, S., Postel, E. A., Connor, T. B., Fekrat, S. 2006; 26 (3): 285-291


To describe the clinical features of persons who developed central retinal vein occlusion (CVO) while being treated with Coumadin for chronic anticoagulation.In a retrospective, comparative, noninterventional case series of patients diagnosed with CVO while being treated with Coumadin as a systemic anticoagulant, visual and anatomical outcomes were compared with those for a cohort of patients diagnosed with CVO who were not treated with any systemic anticoagulation.Fourteen eyes of 14 patients treated with Coumadin were identified. At presentation, the median international normalization ratio (INR) was 2.20 (range, 1.3-5.0). Eight patients (57%) had a therapeutic INR at the time of CVO. Their visual acuity and perfusion status were similar to those of patients with subtherapeutic INR. At the last follow-up (median, 16 months), visual acuity and perfusion status of the group of 14 eyes were similar to baseline findings (P = 0.62). Clinical features and outcomes were similar to those for a cohort of patients with CVO who were not being treated with systemic anticoagulation.CVO can occur in patients being treated with Coumadin for systemic anticoagulation. Final visual acuity and perfusion status were similar to those in a cohort of patients with CVO who were not treated with Coumadin. Although visual acuity is unaffected, ensuring that the INR for these patients remains in the therapeutic range may be important to help prevent secondary systemic thrombotic and embolic disease.

View details for Web of Science ID 000241684700006

View details for PubMedID 16508428

Recurrence of retinal pigment epithelial changes after macular translocation with 360 degrees peripheral retinectomy for geographic atrophy ARCHIVES OF OPHTHALMOLOGY Cahill, M. T., Mruthyunjaya, P., Rickman, C. B., Toth, C. A. 2005; 123 (7): 935-938


To assess the prevalence of recurrence of macular geographic atrophy (GA) of the retinal pigment epithelium (RPE) after macular translocation with 360 degrees retinectomy (MT360) in one institution.A retrospective review of all cases of GA that were treated with MT360 in 1 institution. Demographic and clinical data including the duration of preoperative visual loss, preoperative and postoperative visual acuity, and the prevalence of postoperative foveal RPE atrophy were recorded for these patients, and these data were compared with similar data from patients who underwent MT360 for neovascular age-related macular degeneration (AMD) as part of the prospective Duke Macular Translocation Study, Duke University Eye Center, Durham, NC.Four eyes in 4 patients with GA secondary to AMD underwent MT360 and were compared with 63 eyes in 63 patients who underwent MT360 for neovascular AMD as part of the Duke Macular Translocation Study. The mean duration of preoperative visual loss was higher in the GA group (11.3 months) than in the neovascular AMD group (1.7 months) (P = .08). The prevalence of postoperative foveal RPE atrophy was significantly higher in the GA group (n = 3; 75.0%) than in the neovascular AMD group (n = 5; 8.3%) (P<.01); in the GA group, this corresponded to recurrence of the GA lesions. In contrast, the postoperative RPE atrophy seen in the neovascular AMD group was due to postoperative mechanical forces such as laser therapy or RPE tearing. There was no significant difference in the mean preoperative or postoperative visual acuity in either group.Subfoveal RPE atrophy can reoccur following MT360 in eyes with nonneovascular AMD and GA; RPE atrophy similar to this has not been found in a large consecutive series of patients with neovascular AMD after MT360. Further research is needed to assess if the potential for visual recovery in eyes with end-stage nonneovascular AMD is outweighed by the possibility of postoperative recurrence of GA.

View details for Web of Science ID 000230352900006

View details for PubMedID 16009834

Impact of fluorescein angiographic characteristics of macular lesions on outcomes after macular translocation 360 degrees surgery in eyes with age-related macular degeneration RETINA-THE JOURNAL OF RETINAL AND VITREOUS DISEASES Mruthyunjaya, P., Stinnett, S. S., Toth, C. A. 2005; 25 (5): 597-607


To evaluate the relationship between preoperative lesion size and composition and visual outcomes at 1 year after macular translocation surgery with 360 degree peripheral retinectomy (MT360) for neovascular age-related macular degeneration (AMD).A prospective, interventional, consecutive, noncomparative case series of 64 patients with bilateral neovascular AMD treated with MT360 in the eye with more recent vision loss. Masked reviewers graded preoperative fluorescein angiograms for lesion size in Macular Photocoagulation Study disk areas (MPS DAs) and predominant lesion composition (classic or occult choroidal neovascularization or subretinal hemorrhage). Median changes in distance and near visual acuities and reading speed at 12 months after surgery were analyzed with respect to lesion size and composition.There was no significant difference between the outcomes for small-, medium- or large-sized preoperative lesions. Patients in each predominant lesion composition group had median improvement in visual outcomes with significant improvement in near visual acuity and reading speed for predominantly classic and occult lesions.MT360 stabilizes or improves visual function in patients with neovascular AMD irrespective of lesion size categories and with a variety of lesion compositions. Removal of the subretinal lesion and repositioning of the fovea over a healthier retinal pigment epithelial bed may account for these improvements.

View details for Web of Science ID 000235012800010

View details for PubMedID 16077357

Change in visual function after macular translocation with 360 degrees retinectomy for neovascular age-related macular degeneration OPHTHALMOLOGY Mruthyunjaya, P., Stinnett, S. S., Toth, C. A. 2004; 111 (9): 1715-1724


To measure the change in vision and visual outcomes at 12 months after macular translocation with 360 degrees retinectomy (MT360) and silicone oil tamponade in patients with bilateral vision loss resulting from subfoveal choroidal neovascular membranes in age-related macular degeneration (AMD).A prospective, interventional, consecutive, noncomparative case series.Sixty-four patients with bilateral vision loss resulting from neovascular AMD.Eligible patients had AMD with subfoveal choroidal neovascularization in the operative eye and a maximum of 6 months of central vision loss. Preoperative and 12-month postoperative evaluations included standardized testing of near and distance acuity and reading speed. Patients underwent MT360 with silicone oil tamponade, followed 2 months later by extraocular muscle surgery and silicone oil removal.Change in distance acuity, near acuity, and reading speed at 12 months after MT360 compared with those values before surgery.Sixty-one patients were followed up for 12 months. All eyes were translocated successfully. Median distance acuity letter score improved from 62 letters (Snellen equivalent of approximately 20/125) before surgery to 69 letters (approximately 20/80) by 12 months after surgery (P = 0.03). Median near acuity improved from 0.70 logarithm of the minimum angle of resolution (logMAR) units (approximately 20/100) before surgery to 0.44 logMAR units (approximately 20/55) at 12 months (P<0.001). Median reading speed improved from 71 words per minute (wpm) before surgery to 105 wpm at 12 months after surgery (P<0.001). At 12 months, distance acuity improved by 1 or more lines in 32 patients (52%). In patients with either preoperative distance or near acuity of 20/80 or better, 74% and 95% of patients, respectively, remained in this range of acuity. In patients with either preoperative distance or near acuity of worse than 20/80, 40% and 48% of patients, respectively, improved to 20/80 or better. Postoperative retinal detachment developed in 5 patients (8%), with the macula involved in 2 patients, and all retinas were reattached successfully.Macular translocation with 360 degrees retinectomy with silicone oil tamponade is effective in significantly improving visual function in patients with neovascular AMD, as demonstrated by the improvement in distance and near acuity and reading speed at 12 months after surgery in these patients. Although this is a complex surgical intervention, patients with preoperative visual acuity of 20/80 or better at near or distance are highly likely to retain the 20/80 or better acuity at 12 months after surgery. Macular translocation with 360 degrees retinectomy is an effective treatment option for patients with vision loss in their second eye resulting from neovascular AMD.

View details for DOI 10.1016/j.ophtha.2004.03.022

View details for Web of Science ID 000223606300017

View details for PubMedID 15350328

Diagnostics and therapeutic challenges RETINA-THE JOURNAL OF RETINAL AND VITREOUS DISEASES Mruthyunjaya, P., Fekrat, S., Reed, J. B., Mittra, R., Gallemore, R. P. 2003; 23 (3): 392-399
Diagnostic yield of vitrectomy in eyes with suspected posterior segment infection or malignancy OPHTHALMOLOGY Mruthyunjaya, P., Jumper, J. M., McCallum, R., Patel, D. J., Cox, T. A., JAFFE, G. J. 2002; 109 (6): 1123-1129


To determine the yield of diagnostic pars plana vitrectomy in eyes with suspected posterior segment inflammation or malignancy when clinical examination and systemic laboratory testing did not yield a specific diagnosis.Non-comparative interventional case seriesEighty-seven consecutive patients (90 eyes) who underwent diagnostic pars plana vitrectomy from 1989 through 1999.Vitreous samples were analyzed in a directed manner based on the preoperative clinical examination and systemic laboratory testing.Diagnosis from each test performed on the vitreous samples.Diagnostic vitrectomy was performed alone in 6 eyes (7%) and as part of a therapeutic procedure in the remaining 84 eyes. The diagnostic tests performed most frequently included cytopathology (83%), microbiologic culture and sensitivity (43%), polymerase chain reaction (PCR) (36%), and intraocular antibody levels for T. canis (14%). Of these, intraocular antibody testing and PCR had the highest positive yield, 46% and 39%, respectively. Overall, directed vitreous analysis identified a specific cause in 35 eyes (39%). Of the 65 cases in which an underlying infection was suspected preoperatively, the procedure yielded a specific diagnosis in 27 (42%). When intraocular malignancy was considered preoperatively (71 eyes), a diagnosis of intraocular lymphoma was obtained in seven (10%). This difference between these diagnostic yields was significant (P = 0.02, Fisher's exact test).Diagnostic vitrectomy with directed vitreous fluid analysis yields a specific cause and guides subsequent therapy in a high percentage of cases. This procedure is a valuable adjunct in cases that cannot be diagnosed by less invasive methods.

View details for Web of Science ID 000175762400022

View details for PubMedID 12045054

Clinicomicrobiological review of Nocardia keratitis CORNEA Sridhar, M. S., Sharma, S., Reddy, M. K., Mruthyunjay, P., Rao, G. N. 1998; 17 (1): 17-22


To present the clinical profile, laboratory results, and outcome of treatment in 16 patients with Nocardia keratitis.A retrospective review of 16 culture-proven cases of Nocardia keratitis was done. Clinical and microbiologic data were analyzed.Nocardia constituted 1.7% of laboratory-confirmed bacterial keratitis and was seen predominantly in male subjects (13 of 16) with a mean age of 39.1 years. Although the predisposing factor was unknown in the majority, a definite history of trauma was present in four (25%) cases. Patchy stromal infiltrates were seen in 12 patients. Wreath pattern of infiltrates (six of 16) and hypopyon (nine of 16) were notable features. Nocardia was detectable in corneal scrapings of 10 patients with Gram stain and all patients with 1% acid-fast preparation (six of six). Nocardia asteroides was the causative agent in all except one (N. caviae). All isolates were sensitive to gentamicin; however, topical 30% sulfacetamide was the preferred drug for treatment. Favorable outcome (healed scar) was achieved in 11.Although Nocardia keratitis is a rare condition, a high index of clinical suspicion should be kept in agricultural workers or in patients with trauma who have patchy stromal infiltrates. Sulfonamides are the initial drug of choice, and gentamicin could be an effective alternative. If recognized early, Nocardia keratitis responds to medical treatment with good visual recovery.

View details for Web of Science ID 000071083100004

View details for PubMedID 9436875

Juvenile xanthogranuloma of the lacrimal sac fossa AMERICAN JOURNAL OF OPHTHALMOLOGY Mruthyunjaya, P., Meyer, D. R. 1997; 123 (3): 400-402


Masses involving the medial canthus and lacrimal sac fossa include dacryocystoceles and, less commonly, mucoceles, hemangiomas, diverticula, and lacrimal sac neoplasms. To our knowledge, juvenile xanthogranuloma presenting as a lacrimal sac fossa mass has not been previously reported.We examined a 2-year-old boy who had epiphora in the left eye since birth and a mass in the left lacrimal sac fossa for 6 weeks. During surgery, left lacrimal probing disclosed obstruction at the level of the common canaliculus and lacrimal sac. Exploration and excision of the mass were performed.Histopathologic evaluation disclosed a juvenile xanthogranuloma characterized by an inflammatory cell infiltrate with foamy histiocytes and scattered Touton-type multinucleated giant cells.Juvenile xanthogranuloma should be included in the differential diagnosis of a medial canthal and lacrimal sac fossa mass.

View details for Web of Science ID A1997WM32000017

View details for PubMedID 9063253

Subjective and objective outcomes of strabismus surgery in children JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS Mruthyunjaya, P., Simon, J. W., PICKERING, J. D., Lininger, L. L. 1996; 33 (3): 167-170


The negative psychosocial impact of strabismus in adults has been well documented. Despite the increasingly recognized importance of outcomes research, parents' satisfaction with strabismus treatment in childhood and their assessment of its functional impact and "quality of life" impact have not been investigated.A survey instrument was designed to assess parents' perceptions of preoperative, surgical, and postoperative phases of the clinical experience, including the long-term impact of surgery on their children.Overall satisfaction with the surgical result was rated "good" or "very good" in 85% of 77 children under age 6. The correlation between subjective satisfaction and objective alignment within 10 prism diopters (delta) of orthophoria was significant (P < .001). Parents of children under age 4 noted improved eye contact (61%) and appearance (94%). Parents of older children noted improved interactions with others (47%) and self-esteem (55%). Coordination was considered improved in 56% of the entire group. Subjective satisfaction and psychosocial benefits often occurred even in cases deemed objectively unsuccessful.Surgical correction of strabismus in childhood is clearly perceived by parents to be both successful and important to them and their children.

View details for Web of Science ID A1996UN81900007

View details for PubMedID 8771519